21450 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project identification ` PERMIT NO.
Rullding Address:
10 - 21450
10900 Slaney Ave. , Cu1fartino,. CA 94014
weer•N ams: one: SUBMITTALAPPIJ�noNA
P. G. & Be CITY OF CUPERTINO-BUILDING DIVISION
Contractor.Name; Lie.No: APPLICATION /PERMIT Lr2�
Allied Electric Co 261470 BLDING-ELECnUCAI-nUMBINGMECH LAICAL CATEGORY CONTROL#
UI
Architect/Engineer; Lie.No:
QTy ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addres.: 765 Stockton Ave., San Jose, pERhRTIssuANCE (-Lvc)
LICENSED CONTRACTOR'S DECLARATION.
I hereby aRlrenthat l am licensed under provisions of Chapter9(..C- APPLIANCESRESIDENTIAL JOB DESCR El
ingwilh Sedion 7000)of Dlvidon3 ofthe Businessand ProfeaslonaCnde,and my
YI ION
I'm nas le In(uR Jerre and dfed. 1 PANELS .11
Lianse ClaeaC O Lla# ��O^ G�6��/�10 ` t
at Contractor Gj'77 ec=CECT' IM IQ 2DO AMPS
ARCHITECTS DECLARATION 201-10(a)"P5
re00 Iunderstand my pfamahall be used as public record.. OVERIOOOAMPS SQ.FC.FLOOR AREA
Licensed Prvfeselonal SIGNS ELECTRICAL FINALE
p '
�6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC b �\V,�p\H(/� P
zo baa 0wmghereby a(Rrmthallam31,5,Bfrom
esthe
sad Poefessio License Law fm the L ® ® RVR ■ �C ER
O Z F p counting reason.iredinn 7(DLR limine"and Professions Cade:Any city or TEMP.METER OR POLE INST. \(�`
K ppWWF county whichcture requima permkto alsoreuirestheapmve,dennuch prrepair
O S.c anyatsi ned patementa tsxthat
he
lice sed pursuant to the forsuN peof t e POWER DEVICES / V
y'a E�jj
file a signed statement that he Lc r 9 from penin pursuant it the provisions of the DATE. QOI
3w0 Contractor's License Law(Chapter9(rnm)or that with xempt7000)e Divi- SWIMMING POOL ELECTRIC M\.G
Wfon3 efthe Business and Pro(emWn.Co y violation
Of exempt lhercfromand VALUAT[
the bleb for the alleged exemption. Any vlolatbn of Section 7"13 bS any '�1
G oppBe ntfora permit subjects the eppllcant to
dull penalty of net nn rethan I n OUTLETSSW[TCHESFIX7'URES _t
E
�hundred dollan($500). NEW RESIDENTIAL ELFCTR -
I,as owner of the property,or my employee.with wages as their Ale �'FT STORIES TYPE CONSTRUCTION
comp enation,wBl do the work and thestmcture b not intended or
o((emd for
q vie(Sec 7614,Buameea and Profemion Code:The Co.'.-0e.Lloc x Law
docs mtapply to an nines of Phmugrope whob rmPIild. rimprove'sthereory and OCG CROUP RES.UNITS
whndoea..I workh'— orthrcsaghhia.wnemployeea,provided lhalsuch
improvemenfe are noHntended proffered forsal. If,however,thebuiId!ng or TOTAL;
improvementbaold within oneyear.fcompinbry tM owner-bu0derwfll have t
ter rden of owing
that he did not build or lmpmvefor purpose oI'sale.). QTY, PLUMBING PERMIT FEE F[AOD ZONE APN
u L ae owner of the property,am exclusively contracting with licensed ppgMlT ISSUANCE
contractor to mnaboad the project(Sec.7044,Bush..antl Prefeselen Code:
The Contmdue.License Law does not apply to an owner of property who ALTER-DRAIN&VENT.WATER(EA)
Wilds or improves thereon,and who contracts for such plojeds with a FEE SUMMARY
se eter(s)Ilansed pungent to the Contrader'e License Law. BACK FLOW PROTECT.DEVICE
u I am exempt under Sec B &P C for this means
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Date RFCE'T#
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have n legs a nc of consent d py thereo or'a FIXTURES PER iR/Qs SCI{OOL TA% Y N_
' cenifiLab of Worken'Comperwtlonlruurance orabertlfled copy thereof(See. RFL7IFT#
38110,Lab CJ GAS EA.SY51'FM-1 INCA OUTLETS PARKFEE Y N
Polley# RECEIPTp
Com any GAS EA.SYSTEM-OVER 4IEA) BUILDING DIVISION FEES
Certified copy is herebyfamished. - GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
Certified copy b filed with theecity Inspect..dlvlelon.
CERTIFICATE OF IXEMFTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 20OFC Date Recei Hl
(0 .,Lection need net M<omplcted](the pemit ris(erecta hundreddollars
($100)oreenJ WAMR HEATER W/VENT/ELECTR ENERGY FEE Y N
]certify emptor anypehe roninanronmm ftemonerhe work for tobecfapesubjecrmit is issued, —
I Whale not employ any pecten In any manner ao ae to become subject to ti; WATER SYSTEM/TREATING
Woplican Compenaatien Lwa of Call(omta. Date PAID
C• Z Applicant Date Recel t#
Z O
NOTICE TO APPLICANT: aOrkers'COm er ationkaleo(ons of
the
NEW RESIDENTIAL PCMB. �.FT.
Hshw, ...become subject mime Werken'Compenatlon provisions of the Labor - TOTAL:
N Code,you must(orthwith am ply with such provisions orthls permit shall be WILDING E
LU j deemed revoked,
CL Fm CONSTRUCTION LENDING AGENCY SEISMIC FEE
= Z Ihercbyaffirenthatthereb a construction lendiagagency forthe perform TOTAL: ELECTRIC FEE
once of the work for which this permit is Issued(See.3097,Civ.C.)
0 O Lenders Name PLUMBING FEE
U. F LendcY.Addrcae QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertify that l have read this application and state thatthe above information
C Is corrcn,]agreeto comply with all city countyordinancesand state laws PERMIT ISSUANCE FEES PAID:
} N relating to building construction,and hereby authodze repressota0vea of this
H Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. Dale ReCei tk
(We)agree to save,Indemnify an d keep harmless the City of Cupertino
age Inst liabilities,judgments,costa and expenses which may in any way accrue AIR HANDLING UNITgo 10,ODO CFM) SUBTOTAL:
age a.t.ald City in consequence of t granting of this permit.
# .� AIRHANDUNG UNIT(OVER 10,000CEM) CONSTRUCTION TAX
),nature of Applicant/Contractor Date IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haeardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the - Date Recei til
Ties lth and Safety Code Section 25532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
r_1 Yea M No
Will the applicant or future building occupant use equipment or devices VFMTLATION PAN(SINGLE RESID) 1 Sy1pDATE
which emb it hazardous al,cents releanas defined by the Bay Area Air ro
Quality Management District'
BOILFR-COMP OHP OR 100,000 RTU)
Yes ❑No (��QQ
have read the hazardous material-requlenmmn under Chaptsr6.95of BOILER-COMP(OVER 100,000 BTU)
he
al.
Health&Safety Code,Sections 75505,25533 and 25534.I
understand thatifthe building does not currently have.tenant,that ltbmy NEW RESIDENTIAL MECH. SQ.FT.
respoesibiliy to notify the occupant of the requirements which mu at be met
prior to Issuance of a Certificate of Occupancy.
Ow ��- rl-•+a—y,(�.�r�Q�J�j
ner or authorised agent Date ISSUED B7
TOTAL: r VV•✓
OFFICE COPY