21300 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project IdentificationA �,1� ` hl ��� PERMIT NO.
Building Address: V N 0O
x/60 VA� CO F4ts'IoAl eA L
wnera eine: one: AppLICA nON SUBMi I I AL DA
ML Ael CITY OF CUPERTINOBUILDINGDIVISION
• canctor
16-[-7--q66
APPLICATION / PERMIT
' O <
BUILDINGELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL
Architect/Engineer. Llc.Nie
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
AddressQ ff ss'�7'T !. /���R I'FRh17TISSUANCE I"��ID ❑ ❑ �,
LICENSED CONTRACTOR'S DECLARATION
Iherebyafim,thatlam Bcensed underprovWonsof Chapter9(commenc APPLIANCFSRESIDENIAL ]OB DE 1411.1 ION
Ing with Section 7000)of Division 3 ofthe Business and Professions Code,and my
Lhomse is ien CI full twcq aryldfX O PANELS ` I^ , •r �G'( -+_'T,
Date L- CLlocntntlor
ARCHITECT RATION 201-1000AMPS
w�w Q I understand my plans shall he used as public records. OVER 1000 AMPS,� _ .f SQ.FT.FLOOR AREA S/SQ.FT.
V(Cj Licensed Professional SIGNS ELECTRICAL
«<�y OWNER-BUILDER DECLARATION
I herebyaffirm that l am exem from the Contractors License law for the S IALCRCNT/MLSC�
0 following rason.(Section 7031.5, from
and Professions Code:Any city or TEMP.METER ORPOLEINST.
rr, countywhich requlresa permit tocanvtruct,alter,Improve,demolbh,or repair
anystructure priorto its Lutuance,alsorequirestheapplicant for such permit to POWER DEVICES
tV mS
file a signed statement that he b licensed pursuant to the provisions of the
Contractor's License law(Cha(Chapter 9(comnectin with Pt Rev SWIMMING IDOL ELECTRIC, ) VALUATION
O sion3of the Business and ProfessionsCode)orthat hebexem therefromanC
Q Q 5 the basis for the alleged exemption. Any violation of Sections 7031.5 by any OVR.E' SWITCHES_ A FIXTURES
'
applicant for&permit sub)ectstheappllcanuoa civil penalty of not morethan
rave nanarea collars(ssom.
I hundred
rofthe ro or my employees with ova a their sole NEWRESIDENTI ' ELIEC t SQFT. STORIES TYPECONSTRUCTION
p^ ❑• P Pert)• Ywages as �,
C7a compensation, I willdo the work and the structure b not intended or offeredfor
i 0 sale(Sec 7044,Bwines+ana Prafesloro Code:The Contractors License Taw
�$ does not apply to an ownerof propertywho builds orlmpmvntheroon,and OCC.GROII!' RFS.UNITS
whodoeseuchworkm+
hielf orthrough hisownemployees,provided that such
Improvements are not Intended oroffered for sale.If,howevepthebuildingor s TOTAL:
Improvement la sold within oneyearofcompletion,the owner-bullderwlll have
ltlL¢,raen of proving that he aid not build or Improve for purpose of wle.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
"L as..or of the property,am exclusively currant.,with Ilansed PERMIT ISSUANCE
mntracturs to construct the project(Sec.7044,Businessand Professions Code:
The Contractor's License Law dues not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such plujem with a ALTER-DRAIN&VENT-WATER(EA)
rgdTctar(e)Entreated pursuant to the Contractors License Law. BACR FLOW PROTECT.DEVICE FEE SUMMARY
LI I am exempt under Sec B h P C for this reasonOUTSIDE El Eq
DRAINS-FLOOR,ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPT X
WOR KMAN COMPENSATION DECLARATION pLYNRF_S I'ER TRA)' SCHOOL TAX Y_ N_
01 hereby affirthat I have a cardficate of consen
m t to self-insure,or RECEB X
certlflnte o(Workers'Compensatlonlnsurance ora<ertifiedeopythercof(Sec. GAS EA.SYSTEM-11NCA OUTLETS PARK FEE Y N
3800. ab G.).. GAS EA. BUILDING DIVISION
I'oliryX YV
RECEIPT TX
Com any FEES
�Cedified copyb hereby furnished. GREASE/LNDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
F-lCertified copy V filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE'IRAP PAID
COMPENSATION INSURANCE SEINER-SANITARY-STORM EA 2001-1" Date Receipt#
(Thissection need out be completed if the permit is for one hundred dollars
($100)orIm.) , WATERIiEATEiw/vENr/ELEcrR ENERGY FEE Y_ N_
I mrtifythat N the performance of the work for which this permit is Wood,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workers Compensation laws of California. Date PAID
O Z Applicant NEW RESIDENTIAL PCMB. SQ.FT. Date Reml t#
Z O NOTICE TO APPLICANT:It,a it,,making this Certificate of Exemption,you
shwld become subject to the Warkers'Compensatlon provisions of the Labor TOTAL:
F N Code,you=at forthwith comply with such provisions orthb permit shall be BUILDING W j deemed rcvokeel.CONSTRUCTION LENDING AGENCY SEISMIC FEE .
CL o IherchyafOrm that there b amretruction lending agency forthe perform TOTAL
ELECTRIC FEE V6
M Z ance of the work for whim this permit b Wood(Sec.3097,Civ.C.)
V O lender's Name PLUMBING FEE
LL 1— lcoder's Adders QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OU Icertifythatihavereadthbapplicationand Katethauhe above Information FEES PAID:
W Iscurract.I agree to comply with all city and countyordinancesand elate laws PERMIT ISSUANCE
4 relating mbulldlng construction,and herebyauthorize representativesofthia
F W city to enter upon the above-rrcntloned property for inspection purposes. ALTIRORADDTOMECH.
Z (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Reecipt#
U against liabilities,0dgments,eustesnd expenses which may In any wayacaue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said Ci consequence of the granting of this permit CONSTRUCTION TAX
AIR
HAUSTH G UNIT OD(W/DUCT,t lO,OW CEN)
Slgnaturt pplicant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,ODD BM Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1Z,and the ^
Health and SafeLy Code Section 25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL: 4
❑ Ye rn No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) I$�1 DATE
which emit hazardous air roma Mnanb as defined by the Bay Area Alr �"��
. Quality Management District? BOILER-COMP(3FEa OR 100,IXq BTI)
Yes M No P 4'4p(�
have read the haze ous materials requlerments under Chapter6.95 of BOILER-COMP(OVER 100,000 BN) OCT 71990.
the California Health h SafetyCode,Sections 25505,25533 and 2534.1
understand that if the buildingdoes not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which must be met
priors. ce aCertifi le of Occupancy.
cr r authorizcd agent Dates TOTAL I
ISSUED BY: JV�L✓'`r�
OFFICE COPY