21993 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ea Identification 7 PERMITNO.
Building Addrem: )133 �ST FFd1,U Pik, 21993
a sq y- one: APPMATT579A
l� 1^1 '01 CITY OF CUPERTINO,BUILDING DIVISION
Cont, ' Name: Lie.No: APPLICATION I PERMIT
. Arle
leS BUILDING-ELECTRICAL PLUMBING-MECHAMCAL CATEGORY CON'➢ROL XL"la�
A Itect/Engineer. Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE � �N
LICENSED CONTRACTOR'S DECLARATION Ji
Thereby affirm that l am lcrosed under provisions of Chapter9(commene APPLIANCFSRESID NTIA N JOB DESCRRa1T
Ingwlth5 iun7000)of DiAsim3ofthe Bu,1.,and Pmfes msCode,mdmy �p �
heanx is In(full formal effect. PANELS
let n Cl. lccotractor ?to ' '7✓D OM 5/.S�y�-1 \C
ARCHITECT'S DECLARATION 201-1000 AMPS
(�eeOQ I understand my,plan shall be used as public records. OVERIOW SQ.FT.FLOOR AREA S/e.Q.Fr.
QZ() Licensed Professional SIG S L CAL
6 c� OWNER-BUILDER DECLARATION TRCIR M L
7ti Iherebyafflrmlhatlamexemptfromthe Contractor9 Llanx la forthe
following reason.(Section 9031.5,Business and Profesiom Code:An 'ty or
F45.�F', c.untywhichrequiresapermittocovtmd,alter,impiovgdemolbh,or .METER R L INST.
anystmmmpdortoitsbaaance,aisorequirestheappllantforsuchpermitfo
file a signed statement that he is licensed pursuant to the provisions of the A POWER DEVI �
w Contractor's License Law(Chapter9(commtencingwith Section 7000)of Divi- Sydpd,YgNG I00L ELECTRIC
kon3o/the Buslnesmd ProfesiomCode)orthe helsexempttherelromand - VALUATION
p5p5 �' the basis for the alleged exemption. Any violation of Section 703IS by any
lry�pp applicant for a permit subjects the applicant to a civil penalty a rest ore
t mthi.a"� OUTLETS-SWITCHESF7XTURFS I O
EEEE five hundred dollars($500).I,as owner of the NEW RESIDENTIAL ELECT72
property, my employees g
SQ.FC. STORIES
p perry,or em to en with wages as their sole TYPE CONSTRUCTION
C 7¢ compansatl K will do the Rostrum andwork,andthe u..C dere is not intended o License
d for
Law
� O sale(Sec aptly to an ow andf property Code:The or impdors Llarae Taw
$$ does net apply to an owner.(property who Wilda orimprovnthereoR and
whodoassuch work hiceselforthroigh his own employees,provided that such .GTIS
Improvements are nut intended oroffered for sale.If,hmvevep the W llding or TO
i provementissold within ovyearofcomplalogtheowner-bullderwlli have
tl(LJHrden of proving that he did not baud or lerprova for purpose of sale.). QTY. PLUMBING PERMIT P
LJ I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCEn
contractors to construct the project(Saxe.7o44,Business and Professions Code: 4'
The Contndora License Law does not apply to an owner of property who ALM-DRAIN&VENT (EAI
Wilds or Improves thereon, and who contracts for such pr-ojectn with a
cl5act=s)licensed pursuamtotheCentractors Lkenx Law. BAER FLOW PROTECT.DEVICE FEE SUMMARY
Lf I am exempt under Sec. B&P C for this reason
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
WORKMAN COMPENSATION DECLARATION RWEIY N
T N
❑I hereby affirm that I have a adl(icate of cweent to x8-Insure,or a FIXTURES PER TRAP SCHOOLTAX
adlBamof Workers Compensation Insurance or a certified copythereof(Sec. RECEBT N
38W,Lab C.) GAS FA.SYSTEM-I INCL OUTLETS PARK FEE Y N
Policy N
Ca❑ ny GAS EA.SYSTEM-OVER/(FA) RECEf
VT N
Certified copy Is hereby furnishedBUILDING
DIVISION FEES
Certified copy is filed with the city inspection division. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Ihisaection need not Wcompldml
ed ifthepertisforovhundreddollan SEWER—SANITARY—STORM EA.20OFT. Date Recti t#
(81 W)or less.)
I adlfythat in the performance ofthe work for which this permit is issued WATER HEATER W/VENT/E.ECTR ENERGYFEE Y_ N_
I shall not employ any person in any Banner so as to become subjad to the
O
Workers Compensation Laws of California. Date WATER SYSTEM/TREATING PAID
Z Appliant
Z O NOTICETOAPPLICANT:If,aNer making this Cadlfkate of Exemption,you NEW RESIDENTIAL PLMB.__SQ,FT. Date Reeei t#
should become subject to the Workers Compevatlon provisions ofthe Labor 7 TAL:
N Code,you=at forthwith comply with such ns he
provisioorthis permit shall
W > deemed revoked. BUILDING /e
a p CONSTRUCTION LENDING AGENCY SEISMIC FE I p
I bemby afRrm that them is a construction lending agency for the perform
O anaoftheworklorwhkhthb,permit isisued(Sec.3OWCIv.C.) TOTAL: ELECTRIC E �s
V Lender's Name PLU ING EE
ty F enaersAddre a QTY. MECHANICAL PERMIT FEE H NI L FEE �—
O W IcertlfythatHuvereadthisappuati...nd state thatthe above Inters Ion
is corr<.lagree to comply with all city and county and inanas and state laws PERMIT ISSUANCE AID:
} N relating to building construction,and hereby euthorlas representatives of this
F Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
(We)agree to save,Indemnify an d keep harmless the City of Cupen in, , Receipt#
against liabilities,judgments,cons and expenses which may In any way accrue AIR HANDLING UNIT ITO I0,000CFM) UBTOTAG
against mid C'ty In
sequence.(the granting of this permit.
s— AIR HANDLING UNIT(OVER IO,000 CFM) NSTRUC[I NTAX
S nature of Appuant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTI NTAX PAID:
HAZARDOUS MATERIALS ISCLOSURE
WIIltheapplies nt orfuture building occupant sto®or handle huaroous HEATING UNIT(TO 100,00D BTU)
material as defined bytW Cupertino Municipal Code,Chapter 9.12,and the Date CCCI t#
❑ Y
Health and Safety Cade Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TO A
Y. �No
Will the applhmandntorfututeremong occupant as defined
equipment Area
devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havMous air conlaMnants as defined by the Bay Ara Air
Quality Management District? BOILER-COMP(3HP OR 100,000 BTUs
4hthe
pa A
Yes read thehaxa[r sFF��NomatIr a'V
ave eriaisrequirementsunderChapter6.95of BOILER-COMP BM
the Calilomla Health&Safety Code,Sections 25505,25$33 and 25534. I ���
I
understand that lfthe building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT. _ 'T992
rcvpovibllily to notify the occupant of the requirements which most be met /
up
prior to Issuance of a Certificate of Occupancy. CITY
l 1 Ur L
Ownrror authortred agent Data �f"V
T ISSUED BY:
OFFICE COPY