21593 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —IMRSIFFEL POINT PEN ONLY
Building Project IdentificationPE1iM1T NO.
Building Address:
. 21593 .
woe'sante: one: A
T1 a 'lHb 07yb CITY OF CUPERTINO-BUILDING DIVISION
c doa�ame: Lit Ne APPLICATION /PERMIT L 17
I BUILDINGELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL#
Amhltect/Engineer. Lk,Na:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add—p0 &Qjr 3(n z S64 PERMITISSUANCE hLD(❑ o o
LICENSED CONTRACTOR11
'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapler9(commen, APPLIANCES-RESIDEXIIAL JOB DESCRIPTION
Ingwith S.ed..7000)of Dlvtsto0 ofthe Businessand Pro(esionsCode,and my
License is in full force and effect. t PANELS , l
License Clam C-36 Lt.#
Dated-1 It-9 U Comractor 1UP(1 TO 200 AMPS AMPS
ARCHITE DECLARATION
re z I understand my plans shall be used n public remrda OVER 11100 AMPS SQ.FT.FLOOR AREA 5/SQ.FT
6i Licensed Professional SIGNSELIECTRICAL
C<6 OWNER-BUILDER DECLARATION
i a SPECIALCItCUIT/MLSC
z p,Y� [hereby a ..(S at on 7031 ,Scale the Contransio License lnw(m the
02;:pp followingreason.(Sectionrn0tw Bmtmdandr,ropmns Code:Mytltyir
F.� TEMP.METER OR['OLE[NST.
F� coynst hmhrcqultol p mnce,aL mtquialttheaprovntfor.cher ttr
S any structuretateme t Lathed,also mryknsuant t the provisions
t e ROWER DEVICES
P�O file a actsigned statement that he b Licensed pursuant to the provisions of the
Q6 u,� Contractors License Law nedesaero(mm).othag with Section 7000)of Divi- g(ypt;,`ENG IDOL ELECTRIC
SOS ston3o(lhe Businm and Profmloa Code)orthe he besempttherefromand VALUATION
GS the basis for the alleged exemption. Any violation of Section 70715 by any OUTLETSSWITCHFSFIXTURFS
a pplicantforapemdt.b)e the.Pplic.tt.•dullpemltyanotmorethan
Ove hundred
as
hepro NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPECONSIRUCTION
�n ❑I,as owner of the property,or my employes with wages r their sole
compensation,a0KBusdothawork,endthestrudure Vnor nttended oroffendfor
Osk(See 7066,Business and Profmbns Code:The Contractors License Lw
$ does not apply to an owner of property who Wilds or improves thereco,and OCC.GROUP RES,UNIT'S
who durssurh work hlmselforthmugh hisownemployees,provided thatsuch
improvements are not intended proffered forsale.If,however,thebuilding or TOTAL:
improvement issoldwithin omyearofcomplel Ntheowner-buBderwill have '
thkburden of proving that he did not build or improve for purpose ofsakJ. QTY, PLUMBING PERMIT FEE ,FLOOD ZONE APN
Lf L as owner of the property,am exclusively mnlrading wick Iloensed p�(R ISSUANCE I�
contracturs to construct the prood(See.7614,Business and ProfessionsCode:
The Commetors License Law don not apply to an owner of property who ALTER-DRAIN&VENT-WATER[FA) �s
Wilds or improves thereon,and who contracts for such Inplets with s FEE SUMMARY
SgNTador(e)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sen B&P C for this reason
OUTSIDE FEES
DRAINS• FLOOR ROOF,AREA,COND. SANITARY Y N Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP '�co SQ300L TAX Y N
01h,
M
rely affirm that I leave a certificate of consent to self-Insure,or RECEIPT N
certificate ofWorkets Compensation Insurance ora certified copy thenroffSec. GAS F.A. YSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Lab ft— NN
Pollga GAS IA.SYS OVER )
Com any -a'ter It 0 n P BUILDING DIVISION FEES
ffCertBled copy is furnished. GREASE/WD 'WASTE INTERCEPTOR ( / PL'A CHLCIC FEE
Ified mpy 9 filed with the tltyImpetian division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP,
COMPENSATION INSURANCE SE-WBR-SANRARY-STORM EA IOOITC / /} ate Remi [#
Crhirsedionneedndbecompldedifthep.r tbforomhundeddollan / 7i
(5100)ealm0 WATER FffA cats •RGY EE Y N_
I certify that In the performance ofthe weak forwhleh this permit is blued, -- -t
I shall nm employ any person in any manner w as to become subjed to the WATER SYSTEM/TREATING .
Workeri Compensation Laws of California.Date PAID
Ct Z - Applicant NEW RESIDENTIAL PLMB. SQ-7. Date Recel [#
Z O NOUd ETO mcomeAPPLICANT:a ager makingthb utkm p to o(Exemption,.Lata
shoeldbecomeforth tot he Waken'Compemalon orthiomofthe Labor TOTAL:
N Code,youvoked.forthwith amply will such pros&bns arthls permit shall be BUILDING
W1 deemed revoked.
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
Iherebyaffl ammtaction lending agency for the perform I ELE<_.TRIC FEE
D Laceofthe worork fur winch this permit Issued ued(See C.)3097,Clv. X TOTAL: lW
'
(.) 0 IanderaName PLUMBING FEE ,00
LL H Lander.Addn'N QTY. MECHANICAL:PER MIT FEE MECHANICAL FEE
OW I certilylhatl have read thbapplicationand sWethatthe above Information
6 ismdect.Iagmtocomplywith all cityand muntymelinanmsand Insists s PERMITISSUANCE FEES PAID:
>. N relating to building construction,and hereby authorize representatives ofthis
I- city to enter upon the abow-mentioned property for inspection purposes. ALTERORADDTOMECH.
? (We)agree to save,indemnify an If keep harmless the City of Cu pen loo Date Recei t#
V aga Inst liabilities,judgments,res and expenses which may in any way accrue AIR HANDLING UNIT DO 10W0 CFM) SUBTOTAL:
ago t said City In mmryuence of the grant g of this permit.
Ms
0 AIR HANDLING UNIT(OVER Io,000cr•M)' CONSTRUCTION TAX
jSlgr6preofA Meant/Contractor I Dat EXHAUSTHOOD(w/DUC'D CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT GO 100,000 BTI!) Date Reoei t#
material as defined by the Cupertino Municipal Code,Chapter 9.11,and the -
Health and Safety Code Section 25531(.)7 HFATING UNIT(OVER 100,000 BTIE TOTAL: a00
FI Ye No
Will the applicant Rhine building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISMA. CE DATE
which eoJt hazardous air contaminants as defined by the Bay Arca Air d r
Quality Management Dist Her? BOILER-COMP PEEP OR 100,000 BTU)
Yes ❑❑No
Thaw read the hazardousmaterials requirements under Chapter 6.95of BORER-COMP(OVER 100,000 BTU) T 91! �aClfy
the California Health&Safety Code,Sections 25505,25533 and 25536.1 '4 ; "sKY
It ruiennand that if the building dors not arrently have a tenant that it Is my NEW RESIDENTIAL MECH. SQ.FT '
responsibility to notify the occupant of the requirements which must W met
prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Date TOTAL: ISSUEDBYY
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —IMRSIFFEL POINT PEN ONLY
Building Project IdentificationPE1iM1T NO.
Building Address:
. 21593 .
woe'sante: one: A
T1 a 'lHb 07yb CITY OF CUPERTINO-BUILDING DIVISION
c doa�ame: Lit Ne APPLICATION /PERMIT L 17
I BUILDINGELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL#
Amhltect/Engineer. Lk,Na:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add—p0 &Qjr 3(n z S64 PERMITISSUANCE hLD(❑ o o
LICENSED CONTRACTOR11
'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapler9(commen, APPLIANCES-RESIDEXIIAL JOB DESCRIPTION
Ingwith S.ed..7000)of Dlvtsto0 ofthe Businessand Pro(esionsCode,and my
License is in full force and effect. t PANELS , l
License Clam C-36 Lt.#
Dated-1 It-9 U Comractor 1UP(1 TO 200 AMPS AMPS
ARCHITE DECLARATION
re z I understand my plans shall be used n public remrda OVER 11100 AMPS SQ.FT.FLOOR AREA 5/SQ.FT
6i Licensed Professional SIGNSELIECTRICAL
C<6 OWNER-BUILDER DECLARATION
i a SPECIALCItCUIT/MLSC
z p,Y� [hereby a ..(S at on 7031 ,Scale the Contransio License lnw(m the
02;:pp followingreason.(Sectionrn0tw Bmtmdandr,ropmns Code:Mytltyir
F.� TEMP.METER OR['OLE[NST.
F� coynst hmhrcqultol p mnce,aL mtquialttheaprovntfor.cher ttr
S any structuretateme t Lathed,also mryknsuant t the provisions
t e ROWER DEVICES
P�O file a actsigned statement that he b Licensed pursuant to the provisions of the
Q6 u,� Contractors License Law nedesaero(mm).othag with Section 7000)of Divi- g(ypt;,`ENG IDOL ELECTRIC
SOS ston3o(lhe Businm and Profmloa Code)orthe he besempttherefromand VALUATION
GS the basis for the alleged exemption. Any violation of Section 70715 by any OUTLETSSWITCHFSFIXTURFS
a pplicantforapemdt.b)e the.Pplic.tt.•dullpemltyanotmorethan
Ove hundred
as
the
NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPECONSIRUCTION
�n ❑I,as owner of the property,or my employes with wages r their sole
compensation,a0KBusdothawork,endthestrudure Vnor nttended oroffendfor
Osk(See 7066,Business and Profmbns Code:The Contractors License Lw
$ does not apply to an owner of property who Wilds or improves thereco,and OCC.GROUP RES,UNIT'S
who durssurh work hlmselforthmugh hisownemployees,provided thatsuch
improvements are not intended proffered forsale.If,however,thebuilding or TOTAL:
improvement issoldwithin omyearofcomplel Ntheowner-buBderwill have '
thkburden of proving that he did not build or improve for purpose ofsakJ. QTY, PLUMBING PERMIT FEE ,FLOOD ZONE APN
Lf L as owner of the property,am exclusively mnlrading wick Iloensed p�(R ISSUANCE I�
contracturs to construct the prood(See.7614,Business and ProfessionsCode:
The Commetors License Law don not apply to an owner of property who ALTER-DRAIN&VENT-WATER[FA) �s
Wilds or improves thereon,and who contracts for such Inplets with s FEE SUMMARY
SgNTador(e)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sen B&P C for this reason
OUTSIDE FEES
DRAINS• FLOOR ROOF,AREA,COND. SANITARY Y N Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP '�co SQ300L TAX Y N
01h,
M
rely affirm that I leave a certificate of consent to self-Insure,or RECEIPT N
certificate ofWorkets Compensation Insurance ora certified copy thenroffSec. GAS F.A. YSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Lab ft— NN
Pollga GAS IA.SYS OVER )
Com any -a'ter It 0 n P BUILDING DIVISION FEES
ffCertBled copy is furnished. GREASE/WD 'WASTE INTERCEPTOR ( / PL'A CHLCIC FEE
Ified mpy 9 filed with the tltyImpetian division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP,
COMPENSATION INSURANCE SE-WBR-SANRARY-STORM EA IOOITC / /} ate Remi [#
Crhirsedionneedndbecompldedifthep.r tbforomhundeddollan / 7i
(5100)ealm0 WATER FffA cats •RGY EE Y N_
I certify that In the performance ofthe weak forwhleh this permit is blued, -- -t
I shall nm employ any person in any manner w as to become subjed to the WATER SYSTEM/TREATING .
Workeri Compensation Laws of California.Date PAID
Ct Z - Applicant NEW RESIDENTIAL PLMB. SQ-7. Date Recel [#
Z O NOUd ETO mcomeAPPLICANT:a ager makingthb utkm p to o(Exemption,.Lata
shoeldbecomeforth tot he Waken'Compemalon orthiomofthe Labor TOTAL:
N Code,youvoked.forthwith amply will such pros&bns arthls permit shall be BUILDING
W1 deemed revoked.
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
Iherebyaffl ammtaction lending agency for the perform I ELE<_.TRIC FEE
D Laceofthe worork fur winch this permit Issued ued(See C.)3097,Clv. X TOTAL: lW
'
(.) 0 IanderaName PLUMBING FEE ,00
LL H Lander.Addn'N QTY. MECHANICAL:PER MIT FEE MECHANICAL FEE
OW I certilylhatl have read thbapplicationand sWethatthe above Information
6 ismdect.Iagmtocomplywith all cityand muntymelinanmsand Insists s PERMITISSUANCE FEES PAID:
>. N relating to building construction,and hereby authorize representatives ofthis
I- city to enter upon the abow-mentioned property for inspection purposes. ALTERORADDTOMECH.
? (We)agree to save,indemnify an If keep harmless the City of Cu pen loo Date Recei t#
V aga Inst liabilities,judgments,res and expenses which may in any way accrue AIR HANDLING UNIT DO 10W0 CFM) SUBTOTAL:
ago t said City In mmryuence of the grant g of this permit.
Ms
0 AIR HANDLING UNIT(OVER Io,000cr•M)' CONSTRUCTION TAX
jSlgr6preofA Meant/Contractor I Dat EXHAUSTHOOD(w/DUC'D CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT GO 100,000 BTI!) Date Reoei t#
material as defined by the Cupertino Municipal Code,Chapter 9.11,and the -
Health and Safety Code Section 25531(.)7 HFATING UNIT(OVER 100,000 BTIE TOTAL: a00
FI Ye No
Will the applicant Rhine building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISMA. CE DATE
which eoJt hazardous air contaminants as defined by the Bay Arca Air d r
Quality Management Dist Her? BOILER-COMP PEEP OR 100,000 BTU)
Yes ❑❑No
Thaw read the hazardousmaterials requirements under Chapter 6.95of BORER-COMP(OVER 100,000 BTU) T 91! �aClfy
the California Health&Safety Code,Sections 25505,25533 and 25536.1 '4 ; "sKY
It ruiennand that if the building dors not arrently have a tenant that it Is my NEW RESIDENTIAL MECH. SQ.FT '
responsibility to notify the occupant of the requirements which must W met
prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Date TOTAL: ISSUEDBYY
OFFICE COPY