21688 AI'PLIVANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address: 21688
Al4ll PeP.MOSA. Ave GUplamr1Jo kd� CA cisot
wnercName: one: A
MF-iM UP-L 6L0 CITY OF CUPERTINO-BUILDING DIVISION Z �— q /
C ns Na LI ' APPLICATION /PERMIT
� TEl
� R-- BuicoE23 vY2So BUILDINGELECTRICA4PLUMBINGMECHAMCAL CATEGORY CONTROL a/
Beet Engine,. IGH Q17 Lk.No: �7
O L " 4 4 I BUILDING PERMIT INFO
-3q;;p s
I , 1 1 QTY ELECTRIC PERMIT PEE
Addreu QQ WILLOW ST. -5.J. RSI2 PERAUTISSUANCE � ❑ ❑
��I PLUMB MEL
LICENSED CONTRACTOR'S DECLARATION
I hereby affkm that lam licensed under provisions o(Chaper9(cvmmene APPLIANCFSRESTDENML ]OB DESCRBRION
gwith Seaion7000)of Division3ofthe Buslnessand Profession.Code,and m
1 nee Is In ull fora and died. PANELS
LI aCl. Lice p
Da Contractor - 2011f1D0 AMPS go off- A � �• -
ARCHITECTSDECLARATION
CZ l understand my pons shall be used as public records. OVERIOWAMPS SQ.FT.FLOOR AREA 9//SQ.FT.
.y
Ft C Licensed Professional SIGNSELECTRICAL I /y_ y
<6 OWNER-BUILDER DECLARATION o - 1
G SPECL3LCB2CNT/MLSC
s, thereby a(firm
that lam exempt form lhe Conlcaaor's License Law for the
Z �pp following masm.(Section 7ml.5,Business and Professions Code:Any city or
F�t"W - cauntywhlchrequlmapemdtiommtrud,alter,lmpmvgdemlbh,ormpalr TEMP METER OR POLE INST.
any stmetum prime w its Issuance,abn requlm the applicant for such permit to
POWER DEVICES
file a signed statement that he is licensed pursuant m the provisions of the
3µI- Contactors License Law(Cha pter 9(commencing with Section 7011(3)of Divi- SWIMMING POOL ELECTRIC
sl , UAv —
f„ OJ on3oflhe Busineesand Profeaiom Coote)orthothobommptthomfromand
the basis for the alleged exemption. Any violation of Section 7m15 by anyOUTLETS-SWITCHESFI%TURES
appllant fora permit subjects the applicant to a civil penalty of not=in than
five hundred dollars 0$50E). NEW RESIDENTIAL ELECTR SQFr. STORIES TYPE CONSTRUCTION
❑I,as owner of the property,or my employees with wages as their sole
j:: compensation,wOldothe work and theelmdure is not Intended or offered for
3 F O = ale(Sec 7069,Business and Professions Code:The Contractors License Law
17 fie$ does not apply to an owner of property who Wilda or Improves thereon.and OCC.GROUP RES.UMTS
0. who docssuch work himself w through Msown employers,provided that such
Improvements arc not intended or offered for sale.If,howeveq the building or TOTAL:
Improvement is sold within oneyearof compldfon,the owner-builderwill have
tllLtEurdan of proving that he did not build or impreve for purpose of ale.). QTY, PL T •E DZONE APN
u L as owner of the property,em exclusively contracting with licensedPERMIT E
contactors to construct the project(Sec.7096,Business and Professions Code:
The Contractor's License law does n«apply to an owner of property who ALTER-DRAIN GQ 0
Wilds or Improves thereon,and who cormam f«such Ex jells with a % FEE SUMMARY
cgtpctm(a)licensed pursuant to the Contractors License Law. BACK FLOW PRO T CE
[--]I am exempt under Sec B 4 P C for this reason IES
Owner Date DRAINS FLOOR ROOF,A MTARs( Sa+"N•,_
.ISECEI'f A.
WORKMANCOMPENSATIONDECLARATION❑ F0( gPER TRAP I hereby affirm that I have a certificate of consent to self-nsure,or SCHOOLTAX Y_N��
iRECIDrT a
3800rilab Cf Warkea'Compensatlonlnsra
un«oracertd colse
Biepythenmfc. GAS EA.SYSTEM-1 INCAOUTLEIS PARK FIX Y N
RECEFTM
CoI'. p GAS.EA.SYSTEM.OVER 6(EA)
P�mparay BUILDING DI VISION FEES
1 ICertlRed copy is hereby furnished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy b filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID 1 �
COMPENSATION INSURANCE SEWER-SANITARY-STORM G.200Ff. Date Rgimi t
(Thbseaion need not be completed If the permit Is forom hundred dollars
(SIO0)orlea.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I«dlfythai in the performance of the work forwhich this permit is issued,
I shah not employ any peen In any manner n as to become subject to the _
Workea'Compens.it..Laws of Glifomb. Date WATER EYSIFM/TREATING PAID 12"'
ZZ Applicant NEW RESIDENTIAL PLMB. SQFT. Date Remi t
O NOTICE TO APPLICANT:if,after making this Certlflate of Exemption,you
should become subject to the Workers'Compematlon provisions of the Labor TOTAL:
N Code,you=at forthwith comply with such provblom or this permit shall be B 0
W cl
j deemed revoked. -
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyalOrm that there ba comtmction lending agency forthe perform-
TOTAL: ELECTRIC FEE
O sore of the work"(or which this permit is Wued(Sec.3097,Civ.C.)
Leader'.Name PLUMBING FEE
LL F Iendcr.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I«dlfythat I have read thbapplicationend statethattheaboveiofor tion
IL Is correct.7 agree to comply with all city and county ordinances
and&ate laws PERMIT ISSUANCE FEES PAID:
>• relzHngtabulldlogconstructim sial lumbyauthomemprexntativnofthis
F N city to enter upon the above-mentioned propertyf«Wpschon purposes. ALTER OR ADD TO MECH.
? (We)agree to ave,Indemnify an d keep harmless the City of Cupertino Date Recei t#
() a Virstllabilitles,judg— I mat daxpenses whichnuylnanywayaceme AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL:
a u IdC Inc sen« ft .granting of this perm AIRHANDLiNG UNIT(OVER 10,0 3CFM) CONSTRUCTION TAX
9� C NSQ TR14CTION T ID
Signature of Appgca t onOU Date IXFIAUST FLOOD(W/DUCT) _Ui_ `_I� •
HAZARDOUS MATERIALS DISCLOSURE
Wia the appllant the ure ruin Municipal
Gore hhand le hazardous HEATING UMT(TO 100,000011)) Date RMei tN
material and
defined by the Cupertino MuNdpal Code,Chapter 9.1;and the
I lealth and Eatery Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yo No
Wlllthe eppll«nt orfuP]ture building occupant use equipment or devices VENTILATION PAN(SINGLE REEID) ISSUANCE DATE
s,hich emit hazardous air contaminants as defined by the Bay Area Air q
Iity Management DisWd7 BOE.ER-COMP OFB'ORif10,0008'Hn T
I'I Yes Q No
vo read Healthe h
a sus moon, requirements 5,2553 Chapter 25534..95 of BOfLER-COMP(OVFR 100,000 BTU) APR 31991
th California Health&Safety Code,Sections 755QS,75533 and 255M. I
u sola nd that if the building don not mrrently have a tenant.that It is my NEW RES[DFI-SIAL MECH. SQFF.
ponsholity to notify the occupant of the requirements which must be met
I'
for to issuance of a CediBmte of Occupancy. (,tply l
Owner or authorized agent Date ISSUEDBY:.aa b
TOTAL:
OFFICE COPY