21672 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PER.MITNO.
BandingAddrex \Wo 21672
core ams:
i2onn
S & u q co CITY OF CUPERTINO-BUILDINGDIVISIONgift Q /
c naetar Name: LIc.Na APPLICATION / PERMIT L
��A $ 1 "'rTe,V GTI(),jCo 4�3 ! BUILDMGELECTRICALPLUMBINC MECHANICAL CATEGORY CONTROL*/3
Architect/Engt Lk.No: Ib F--�
TJ A
QTY ELECTRIC PERMIT PEE BUILDING PERMIT INFO
�{—�
Address , PERh1ITISSUANCE -DD
LICENSED CONTRACTOR'S DECLARATION
I hembyafflrmthat lamlicensed under provisionsof Chapter9(comenenc APPLIANCES-RESIDENTIAL JOB DESCRIVITON
Ingwith See1on7000)of Dlvlsion3 ofthe Busloessand ProfexionsCode,and my
license la In full and effect CR �k-
PANEIS
License lase ret Lic.p 4ejt
Date Conbudor ,��� =000AMP5
ARCHITECPS DECLARATION OVERIOOOAMPS SQ.FI.FLOOR AREA $/SQ.FI.
0'/- Iunderatand my plan shall bcuxd as public records
O
Licensed Iharexiovl SIGNS ELECTRICAL
Cm OWNER."
UILDER DECLARATION
SPECIAL CIItC[BT/MISC
79..�G owing reason.
mction7 1.5,Buempt siness
Contrzdors License Law fort he
following mason.(Section 7011.5,Business and Pro(exlona Code:Any city it
F �, TEMP.METER OR POLE INST.
hQ county which rcqulrcsa permlttorovtruct,alter,Improve,demolish
a anystmmmpdortoibW ance,aisomquW stheappBvntforsuchpem ito POWER DEVICES
r1v U Ble a signed statement that he Is licensed pursuant to the prov6bns of the
, COme Contractor'sLicense Law(Chapter 9(commencing with Section 7000)of Owl- SWIMMINGPOOLELECDUC
OQ Mon 3 of the Business and Professions Code)or that he Is exampttherafrom and _ VALUATION �O
EF?^, 6•5.t
the basis for the alleged exemption. Any violation of Section 70]15 by any OVfLETI-SWITCHESFIXTURFS Q �B
applicant for a permit subjects the applicant to a civil penalty a not room than
R five hundred dollars($500). NEWRESIDENTIALELECTRSQ.Ff. SIO ES TYPECON'STRUCTION
..
F-1 1,as owner of the property,or my employees with wages as their sole
k7Q compensation,wlllelothe work,and thestructure(a not intended or offered for
ec
s ❑
.Is(S 7044,Business and Professions Code:The Contractors License Law
$$ does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RES.UNITS
who does such work himself or through his own employees,provided that such n
Imm
proveents are not intended or offered for sale.If,howeveq the build Ing or TOTAL: O
improvement lssold withinoneyearofcompletiorytheowner-buBderwill have
thFtIurden of proving that W did net build or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD TDNE APN
u 4 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractor to construct the project(Sec 7044,Business and Professions Code:
The Contractors License Law does one apply to an owner a property who
Willa or Improves thereon,and who contracts for such psojea»with a ALTER-DRAIN&VENT-WATER[FA)
coJR(aetm(0 licensed punuant to the Contractor's License Law. FEE SUMMARY
LJ I am exempt under Sec. B k P C for this reason BACK FLOW PROTECT.DEVICE
OUTSIDE ITES
Owner Date DRAINS FLOOR ROOF,AREA,CONE. SANITARY RlFCEQTa
WORKMAN COMPENSATION DECLARATION FI%TURES PER TRM SCHOOLTAX Y N
01 hereby a(flrm that 1 have a certificate of consent to seB-metre,or RECEIPT 0
certiBate ofWorkers'Compensation Insurance ma artlfld copythemof(5sc. GAS EA.SYSTEM-I INCA
0ITILEIS PARK PEE Y N
3800,lab C.) RECEIPT X
Policy R GAS EA.SYST[M-OVER 4(EA) BUILDING DIVISION FEES
Company
f I Certified copy is hedwith the cit. GREASE/INDUS)RL WASTE INTERCEPTOR PLANC14ECK FEE
Certlfled copy b(Ikd with the city Inspection division. '76,
CERTIFICATE OF DEEM PTION FROM WORK ERS' GREASE TRAP PAID
t COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FI Date RCCCI t#
(This section need net be completed If the permit is for one hundred dollam
($100)or lex.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I certifythat In the performance of the work for which this permit Is Issued,
I shall not employ any person In any manner m as to become subject to the WATp9 SYSTEM/TREATING
Workers'Compersation Laws of California.Date PAID
O Z Applicant NEW RE9DPNTIAL PIMB. �FI. Date Recei tq
Z O NOHCETO APPLICANT:10fer mvkingthIs CertBlateof Exemption,you
Hshould become subjecttothe Wmkers''Compevatmn prov6lonaofthe Labor TOTAL:
N
Code,you=at forthwith comply with such provisions orthis permit shall be BUILDING FE �• d
j decreed revoked.
W _ mCONSTRUCTION LENDING AGENCY SEISMIC FEE �a 0
Q. I hereby affirm that there Is a construction lending agency for the perfmm� TOTAL: ELECTRIC FEE ��
U7 Z ance of the work for which this permit Is twed(Sec.3097,Civ.C.)
O Landers Name PLUMBING FEE
LL f Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
W berated.Imdifythatlhavereadthtsappl tianandatatethattheabovemfomution
O Iagreetocomplywithalldtyandrountyordlnancesand state laws PERMITLSSUANCE FEES PAID:
} N relating to building construction,and herebyamhorium representatives ofthis
h Z enyto enterupon the above-mentioned property for inspection purposes. ALMORADDTOMECH. Date Receiptk
V (We)agree to save,indemnify an d keep harmless the City of Cupertino
a galosthitbilides,judgments,coasand expenseswhich mayin anywayareme, AIR HANDLING UNIT 8010,000 CFM) SUBTOTAL: 1
get t I en o(the granting of this pc t.
d`� /�4/qj AftHANDWNG NTC OVERIO,000CFM) CONSTRUCTION TAX
SignaturemApplicant/Contractor ,I to EXHAUSTHOOD(W/DUCI) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO lffl W0 BTU) Date Receipt#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the -
Health and Safety CadeeSection 25532(a)2 HEATING UNIT(OVER 100,00)BTU) TOTAL:
❑Yea M No
Willtheappliciud criff4tureWildirtgoccup.rd useequlpment ordevices VEDfDLATTON FAN(SINGLE RESID) c ISSUANCE DATE
which emit havrdous air contaminants as defined by the Bay Arca Air PAID Quality Management District? A
BOILER-COMP OHP OR 100,0(0 BTU) _
p❑Yes No
' Ihave read the hazrousmaterials requirements under Chapter 6.95of BOILER-COMP(OVER 100,OW BTU) p 1991
the California health A Safety Code,Sections 25505,25533 and 25534. I JAN 9
understand that if the Wilding does net currently have a tenant,that it is my NEWRISIDENTIALMECH. SQ.IT.
responsibility to notify the occupant of the requirements which most be met
prior to lana tics of a Certificate of Occupancy. My IIIcuwCh�
`s
Owner or authorlud TOTAL;agent Date ISSUED BY,
,YVwM yyv
OFFICE COPY