21427 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 21427
1 q one: A A
Owner a0 I/ '(,�SO-l(� S—63 CITY OF CUPERTINO-BUILDING DIVISION L Z—(.`�O
c° ' �'^'� W LkN`o APPLICATION 1 PERMIT
.� LE-dr ArcM1ited/Fng/nnr. BUILDING-ELECTRICAL PLUMBING-MMHAMCAL CATEGORY CONTROL a
Lic.No.
QTY ELECTRIC PERMIT F E BUILDING PERMIT INFO
Address:
I'FRMITISSUANCE El ❑ El M
LICENSED CONTRACTOR'S DECLARATION
I hereby
lam licensed under prwWonaof Gapler9(mmmrnc APPLIANCES-RESIDENTIAL - JOB Dig tIa'TTON
hemse5edion 7000)of Division3o( eBusinessand Professlone Code,and my
hnnse b in d effect. tea ) PANELS
Limsse Cl4A,L�` LIc.N �-/0� '• - ' '—
Date •f'r/n� Commuter
ARCHITECT ION 201-IOW AMPS
µof re0 7777 I understand my plans shall be used as public records. OVER IODO AMPS SQ.FT.FLOOR ARG f/SQ.F7.
Li sed Professional SIGNSELECTRICAL
a.4 OWNER-BUILDER DECLARATION SPECIAL CIRCIAT/MISC
71.., a Ihembyaf . hat l am exempt from the Contractor's License Lawforthe
following reason.(Sedloe 7071.5,Business and Professors Code:An or
Ff'� county which requires a permit to coretmct,alter,4nprove,demoLLsh,or pair TEMP.MITER ORPO INST.
m`•B a anystructure Inform its Encases,also esqulresthe applicantfor such permit to
C` file a signed statement that he E licensed pursuant to the provisions of the EWER DEVICES
Contractors Llcems Law(Chapters(commencingwith Semon7000)of Divi- SWIMMING LELECTRIC
�0a Ann 3 of the Bualoessand Professions Code)or that he b exempt therefeemand VALUATION
Y.'•..tt the bash for the alleged exemption. Any vlolatbn of Section 70315 by any
�m applicant for a permit subjects the applicant to a civil penalty of not more than OUTLE TCHESEXTURiS
five hundred dollars(S500). NEW DENIAL ELECTR
I,as owner of the ro SSQt F. STORIES TYFECONSIRUCTION
�4 ❑ e pert.,or employees
campeesat00A wuldo the work,and thenhade:The
not intended or offered for
C 0 dale(see.apply
to an essow and f property
rope ty hose:The G improsea Llmme law
5$ don doet es
loan owner ofthroug his one mporimprovesthereoryand OCCGROUP RES.UNITS
E•
who doessuch work himself or/hrough hleownemployees,provided that such
Improvements are not Intended oroffered forsale.If,howevep the bulldingor TOTAL:
improvement bsotd withinoncyearafcompletfor,the owner-bullderwl 11 have
t"rdmof provimgthat he dideot build orimprove for purpose of sale.). Ty. PLUMBING PERMIT FEE Fl.00D ZDNE -PN
LJ L as owner of the Property,am exclusively contracting with licensed -
contractors to ronutruct the project(Sec.7044,Business and Professors Code: PERMIT ISSUANCE
The Commetorb Llmose Law don not apply to an owner of property who
buildsALTER-DRAIN&VENT-WATER(G)
or Improve thereon, and who contras for inch pNleda with a
ad°r(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT. FEE SUMMARY
I am exempt under Bee. B& P C for this reason
7— OUTSIDE ITFS_
Owner Date XFA41FA)
FLOOR ROOF,AREA,CONE. SANITARY Y_ N
WORKMAN COMPENSATION DECLARATION RECEIPT#
hereby affirm that I have a certificate of consent to self-Insure,or a S PER Tom' SCHOOL TAX Y N
rani care o(Workeri Compensation l�suranreora rertified copy tM1enrof(Sec. RECEIPTk
380),Lab C. .SYSTEM-1 TNC.4 OUTLET'S PARK FEE Y N
PcllryR W ��aZ- EA. RECEPT#
Gompaev_ pr'-^—( tlU1LDING DIVISIONFEES
❑certlnea eapyE er mmlahea. /WDUSIRL WA FrTOR PLANCHECK FEE
�ertified copy b Bled with the sty inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' TRAP PAID
COMPENSATION INSURANCE
(This section need not be completed if the permit E forces hundred dollars SANITARY- RM EA.200FT. Date Recel ted
(Sl0))or lay.) HGTER ENERGY PEE Y NI certeythat In the performance of thework forwhich this permit is issued, /VENT/ELECTR I shall not employ any person In any manner so as to become subject to the SY /TREATINGO Wor'eerrs'Compensation laws of California.Date PAID
PP AL PLMB.__SQ.FT. DateZ 0NOTICE TO AI'P[.ICANT:H,after making the CemRkate ofxemption,ycushould become Subject to the Warkee9'Compensation pmvBlora ofthe LaborTOTAL:
Code,you must forthwith comply with such provblons orthb permit shall beW > deerted revoked. BUI DIN FE•do CONSTRUCTION LENDING AGENCYSEISMIC PGE
I herebyaffirmthat there Eaconstruction lendingagency forthe perform- ELECTRIC FEE
L) O ance of the work for which this permit b Issued(Sec.3097,Cle.C.) TOTAL:
V _ Lender's Name PLUMBING FEE
ly enderbnddresa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iceatify thatl have read thbappliotion and stauthatthe above information ,
cored.l agree to comply with all cityand county ordlnarms and state taws PERMIT ISSUANCE
a /2 FEES PAID:
} N Lt.-
relating building mmtmdlon,and hereby authorfu rcprexntativn of this
{— Z city to enter upon the above-mentioned property for lmpmion purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
against liabilities, mats and expenses which may In nywayaccme AIR HANDLING UNIT(To 10,Bdo CFM) SUBTOTAL,
at slit Ci c sequenceof the granting of thlry
gains .1
1 / AIR HANDLING UNIT(OVER IO,WDCFM) CONSTRUCTION TAX
Signat of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PA ID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a pPlicamt or future building occu pant a tore or hand lc havamous / HEATING UNIT(TO 100,000 BTU) aaFyP��
material as defined by Cupertino Municipal Coda Chapter 9.12,and the 'v4/ .Date RCCei t#
Health and Safety Cede Section 2553Ha)7 HEATING UNIT(OVER 100,000 BTUs TOTAL: O�
❑ Yes M No
Will theappBont or future building past equipment or devices VENTILATION FAN(SINGLE RESIDM. TOTALIM ISSUANCE DATE r
which emit hazardous air contamlm rata as defined by the Bay Area Air
zu
Quality Management Distridl 100,000 BTU)
4 Yes No �
have read thahuar eua matariab requirements under Chapter 6.95 of BOILER-COMP ,OW BTU!!
r the C,illfornla Filth&Safety Code,Sedloms25505,25533and2S534. I
and matand that Off thebullding does not currently have a tenant,that it is myH. SQ.FT I'FV �.� ���
rrspoeaubilltytonalfy lheompan'of the requirements which must be and1. V
prior to issuance of a Certificate of Occupancy. 1 99
Owner or authonwd agent DateI B/tgif lslfG};i.•�}�s. l\ Ara
TOTAL: SSUEV �f YEJC•
OFFICE COPY