21808 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buudm Project Identification PERMIT NO.
Building Address:
T 21808
ner / /�/ one: A A A
5 A6 ��j� CITY OFCUPERTINO-BUILDING DIVISION
�C: "t""o °N' : Lk.No: APPLICATION /PERMIT
BUALDINC-FI,ECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL N
rchitact/Engineer. Lie No:
�
/ /� v� QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERh9TIS5UANCE t�,,� ❑
LICENSED CONTRACTOR'S DECLARATION
I Mreby affirmthat l am Bcm.ed under provisions of Chapter9(commenc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingw+th SecHoo7000)of D vision 3ofthe Businessand PeefessionsCode,and my
license Is+n full fo nd effect. PANELS Q '�y�
LlmnseCka Lfe# �� GFFk �►-� b-IPd.�3s
Date1—�:Contractor
ARCHITECTS DECLARATION MI-1000AMPS
�Z I understand mypbreshallbe used as publicre order OVERtODOAMPS SQ.FT.FLOOR AREA $/SQ.PT.
O
X Licensed Professional SIGNS ELECTRICAL
Ga. OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC
IherebyafBrm thatI am exempt from the Contractor.License Law for the
following reason.(Section 7031.5,Business and Prefeas+ons Code:Any city or
62g,45 , mcnty which mqulma permRtocomtmct,alter, P TEMP.METER OR TOLE INST.
K2gprove,demolish,Dere air
m E.a any stmMmpdortoltatsuance,al requimtheappliantforsuchper do
6K U life a signed statement that he Is
licensed pursuant to the provisions of the POWER DEVICES
03 mI; Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWTMN.ING POOL ELECTRIC
09bn3ofthe Busin..rd1 Peefnagmu Code)mthat he Isexempttherefromand VALUATION
Wo5 the basis for the alleged exemption. Any violation of Section 7011.5 by any C D OUTLETSSWITCHESFIXTURES �, co2 p pa;Od
GX applicant for a permit subjectsthe applicant to a civil penalty ofnot more than
a five hundred dollars($500).
NEW RESIDEN'IIALELECTRSQ.FI', STOMPS TYPE CONSTRLX:TION
7 ❑1,as owner of the property,or he employees with wage as there sole
compensation,willchothBusiness work andthes Code:Th Contrandedo License Law
D
sale(Sec.704Apply to anosandf property
Code:The ContractorsthemeIad
whodonet apply roan owner ofprough whonemlds orimprovoted that such
OCC.GROUP RIS.UNITS
whoovessuchments am not msendedorwghhis ors e.If,ho es,providedthatsn or
Improvement arc not Intended proffered for sok.If,however,the Wildingrn TOTAL: , (�
Improvement Is sold within oneyearofcompletion the owner-builder will have
ur nien of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE pi, Dzc N, ppNr
LI I,as owner of the property,am exclusively contraRing with lkens d r PERMIT ISSUANCE a.gs
contractors to construct the project(Sec 70K Business and Professions Code: 1 I ZcCZ
The Contxctorb License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) _
Wilda or improvesre
thereon,and who contracts for such projects with a
c75actor(a)Ikensed pursuant to the Contractor's License Law. gp(R FLOW PROTECT.DEVICE FEE SUMMARY
Lj I am exempt under Sec B k P C for this rea nn
DRAINS FLOOR ROOF,AREA,CONT). SANITARY Y N—
• OUTSIDE rrr—q
Owner Date RRCEPTN
WORIOdAN COMPENSATION DECLARATION FDCrURES PER TRAP e1� SCHOOL TAX Y N
❑1 hereby affirm that I have o ce rifiestesurenn of consent to self thereof
ora Ga RECEIPT N
certificate mfWorkeri Compensation Wurance ora certified copy thereof(Sec. GAS F.A.SYSTEM-1 INCL OUTLETS
3800,Lab C.) PARK FEE Y N
Policy N RECEIPT N
C
ray CAS EA.SYSTEM-OVER d(EA)ECertified copy Is herebytumcity Inspection
DIVISION FEES
❑Certified copy Is(fled with the cityInspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
Cm becom
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA"Fr Date Re j t#
(Thr aectbn need fiat W completed tithe permit at(or orae n
hundred dollars
($1 ariffyvd WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I cent employ
o any person
i an the work as to h this Permit is issued, —
I shall not employ any.exon in any nunner at u to become objet to the WATER SYSTEM/TREATING
Worlicant ompewtion Laws o(Gllfmmia.Date PAID
O Z Applicant NEW RESIDENTIAL I'LMB.
Z O NOTICE TO APPLICANT.If,after maklog this CertBiateof Exemption,you SQ.FL Date Recei t#
sode,yo at forthwith
the Work en'such pwHkma rthbpernst be
TOTAL:
WN Code,you muat(arthwith comply with such provlalana orthIs permit shall be
> deemed revoked. UI ING FEE - rjt UO
11 c CONSTRUCTION LENDING AGENCY SEISMIC FEE a p
Ihembyaffirenthatthembammtmctton lendingagency forthe perform ELECTRIC FEE
(y (�
Z ance of the work f..which that permit u L
Issued(Sec.3097,Civ.C.) TOTA .l x
V O Lender.Name - PLUMBING FEE
LL F— Lender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W lcertifythatl have read thatapplland tionastate that above information
a Is come".I agreeto comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID;
>. W relating tobulldiVgmestmetion,and lumbyauthomerepreeentativesofthIs
Z cityt.cete,.poathe above-mentbned property for inspection purposes. ALTER ORADDTO MECH.
V — (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
fgairst liabilities,judgment oat sand expenses which may in anywayacrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
st a ty in once ce of he granting of this permit.
- 9 AIR HANDLING UNIT(OVER 10,000 Cm) CONSTRUCTION TAX
turcof App n ontrator are EXHAUST HOOD(W/DUCT) CONSTRUCFIONTAX PAID:
H eco'
MATERIALS DISCLOSURE -
Willtheap licant or
building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date
metonalas defined by the Cupertino Municipal Code,Chapter 9.IZ and the Rttei t#
I Ic.Ith and Safety Cade Section 75532(a)? HEATING UMT(OVER 100,000 BTU)
❑ Ye. r]No TOTAL: x
Will the zpplicant onfuture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) A
which eMMa d
t haeanlous air centaoantsefined 1$$JNCE DATE
by the Bay Area Air LA _—
• Quality Management District? BOILER-COMPPHPOR 100,000 BTU) "P"sA-�BR'�Jfl
Yea II�II No
have read the hazaiZous materials requirement under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) FC1} Ty-a�
the California Health&Safety Code,Sections 25505,25533 and 25534.I LFM� 11`9
understand that lithe building does not cumntly have a tenant,that it 6 my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which most be met
prior to issuance of a Certificate of O=pa ley.
Owner or authorlud agent Date L'Y�ql}f/ f
TOTAL: ISSUED BY:
OFFICE COPY
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