21847 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification I PERMIT NO.
Building Addrev:
< to v, 21847
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More: SUBMITTALAPPUCATION AIT:
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$ —0? CITY OF CUPERTINO-BUILDING DIVISION
cantor''racante: Lic.No: APPLICATION IPERMIT 2
ZAi YN c= '- BUILDINGdECTRICALPLUMBINGMECF LAICAL CATEGORY CONTROL N
Architect/Engineer. Lic.No:
QTY ELECFRICPERMIT FEE BUILDING PERMIT INFO
Addrea% N'19 O/'
PEtMIr ISSUANCE ❑ ❑ ❑
LIm that ED CONTRACTOR'S DECLARATION
Hereby
tbatlamlkm3.fth.under provisions ndPmfehapter9(commenc- APIPLIANCFSREADENTIAL JOB DFSCRR?ION
increeiSection 6m,anDlvfect. (theBminenand ProtesalonaCaae,and my
liana Is In fuse fpm d effect. PANELS
Llan.eC ass - m Lic p_!- I2�E{9
Date fl 1 _I_ComraRor 'TaiMI�rry
ARCHITECTS DECLARATION 701-1000 AMPS
I urairm and my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA E/�.FI.
WLicensed Professional SIGN'SELECTRICAL
6 f OWNER-BUILDER DECLARATION SPFfL1LCIRCUIT/MISC
i.., 7n Ihernbm
yalOrlhaam
t l exempt incentive Contractor's License law for the
oo following reason.(Section 7011.5,Business and Professions Code:Any city or
FaZF camtywhich requiresa permit tommami alter,improve,dernalbh,orespair IFAiP.MECEt OR POLE INST.
645�� anystruaure polar to its Wu a race,aka requ tom the a ppBesot for such permit to
YK` file a signed statement that he Is licensed pursuant to the provlalors of the BOWER DEVICES
Ow Contractor's License Law(Chapter 9(mmmencing with Section 7000)of Divi- SWIMMING Il)OLELECTRIC
30r" sloraoftheguslnessand Pro(eaaloa Ccde)orthat he b exempt therefromand VALUATION
G the basis for the alleged exemption. Any violation of Section 70115 by my I AAi�l.s
applicant for a permit subject the applicant to a civil penalty of net morethan OUTLEISSWI7CHESF[XTIIRFS l� oV r a¢J
a five hundred dollars(5500). NEW RESIDENTIAL ELECTR
I as owner of the SQFI. STOIUFS
❑, ewpzrty,ormyemtureisswithended r ffered for
elrwk TITPE CONSTRUCTION'
]Q ask CScompo7t ZwBldoss,and rohathes Codi,:
Cintended License Law
a O ask l5ec.7616,Buainna and[hvfesslom Coate:The ContnctoYe License Law
does not apply to m owner of property who builds or improves thereon,and OCC.GROUP RIS.UMTS
C0.• whodossuch work himself orthrough Haman employees,provided that such
Improvementsare not Intended oroffered for sak.IL however thebullding or TOTAL:
m
Improveent la sold within oncyearofcampletloo the owner-bullderwill have
ihe4urden of proving that he dm not bund or Improve for purpose of cake). QTY. PLUMBING PERMIT FEE FIpp z,pN ApN
LI L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
comracton to contmet the project(Sec.7044,Business and Professions Code:
The Cont actor's Liceme Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA)
Wilds or Improves themmn, and who contract for such piyjects with a
m,,IIRRfraaor(.)Reamed pursuant to the Contractor.Lt...Law. FEE SUMMARY
151 am exempt under Sec. B k P C for this mason BACK FLOW PROTECT.DEVICE
• Owner Date DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y_ N
WORKMAN COMPENSATION DECLARATION RECEIPT N
f_11 hereby affirm that I have a certiDate of consent to sell-In Lure,or a F'DaVRES PER TRAP SCHOOL TAX Y_ N_
certificate of Workers Compeouation Irsumnmora cedifled copythereof(Sec. RECEPr!
380,Lab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Policy M RECENT if
Com ny GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FRES
�Cedifled copy bffledwtumecity1.b1 GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑cemned ropy la rhea with the dry Inspection alwamn.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANTTARYSIORM FA 200£1. Date Recet t#
Thor aecdon need not W completed i(the pnrtmt la(or oro hundred dollar
(5100)dify that
WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
Icedify that Nthe performance of the work forwNch this permit is cawed, —
I shall not employ any person in any manner n n}}QQ bamme , mile WATER SYSI,EM/TRE).TING
Workers'Compmti.nLawsof Califyr�is.Date_'4 I L PAID
O Z Applicant %ArA g b XJF f/`F NEW RESIDENTIAL PLMB. SQ,FI', Date RCCei t#
Z O N'OTICETO APPLICAN 1;U,after making this Certificate of Exemption,you
should become sub),&to the Warken'Compensation provisions of the Labor TOTAL:
WN Code,you most forthwith comply with such provision or this pemdt shall be
> deemed revakcd. BUIL12ING FEE CSO
CL ONSTRUCTION LENDING AGENCY SEISMIC FEE O
I hereby alarm Cthat there is a conatructlon lending agency for the perform-
7 Z ance of the work for which this permit is Wood(Sec.3097,Civ.C.) TOTAL:
ELECTRIC FEE
O O lend``.Name PLUMBING FEE
LL ~ LendersAddrom QTY. MECHANICAL PERMIT FEE
O W Icertilythatl have read thisappBationand state thatmeamvelnumnatlon MECHANICAL FEE
M Is mnect.l agree to comply with Ali city and county ordinance and date laws PERMIT ISSUANCE FEES PAID:
>. Wrelating to building convuRlon,and hereby authorize representatives of this
H Z city to enter upon the aWv nnvrtioned property for Inspection purposes. ALTER OR ADDTO MECH.
V — (We)agree to ave,indemolly an d keep harmlen the City of Cupertino Date Receipt#
against liabilities,judgments,costs a nd expenses which may in any way accrue AIR HA NDLING UNI'fro ID,000 CFM)
agaitsam Ch I nugamaaf the un Mori. SUBTOTAL:
R granting permit.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Sig sere a(Appllant/Contactor IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfutumbullding occupant storeor handle hazardous HEATING UMT(r0100,ODD BIIn Date Recei t#
material as defined by the Cupertino Municipal Cade,Chapter 9.17,and the
He❑ ❑
Yes elthand Safety Code, No
Section 75525532(a? HEATING UNIT(OVER I00,000 BTU) TOTAL-
Will the applicant or future Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havrdous air contaminants m defined by the Day Arca Air
Quality Management District? BOILER-COMP OHP OR 100,0()BTU) ���
Yes F No
hove rcadtheh r�r .0 ater.l rrequlremcnbunder Chapter G95of BOILER-COMP(OVEr 100,000 BTU)
the California Health k Safety Code,Sections 25505,25533 and 25534. I
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. ';C0 ] 1891
responsibility to rally the occupant of the requirements which must be met b 4
prior to Lasuance of a Certificate of Occupancy.
Owner or authodud agent Date ISSUED BY:�
LUTA L:
OFFICE COPY