22410 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: �� A q O
21 nd� �n T4I
sero aces: - one: AFPU�110N SUBMI MA=
CITY OF CUPERTINO-BUILDING DIVISION
Contractors Name: LIc.Ne: APPLICATION / PERMIT
lk /
BUILDING-ELECTWCA4PLUMBINC-MECHANICAL CATEGORY CONTROL#
Archltea/Englmer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
r7j
J'L
Add— 4h s / PERMITISSUANCE � ❑ [1LICENSED CONTRACTOR'S DECLARATION
I hereby affurnthat l amllcased under pruvisionsof Chapter9(commune. APPL(ANCESRESIDENTIAL JOB DESCRIPTION
Ingwilh SecBon7000)of Dlvlslcn3 ofthe BuYnesand ProfeslonsCode,and my
license is in f d effect PANELS
Lire Cl Lk.NnlLi _
Dale Coratlor T1nk.T'
AACHITECPS DELLA N 201-1000 AMTS
pqqp±± O I understand my plans shall be used s public retards OVER late AMPS SQ.FT.FLOOR AREA $/SQ.FT.
E d Licensed Professional SIGNS ELECTRICAL LED ' N
<6 OWNERexmptfro DECLARATION /ate
Ian] SPECIAL CIRCUIT/MISC �'N(`
I hereby afflrmthat I am exempt from the ContraRor'e License Law for the
7o following reason.(Section 7031.5,Business and Professions Code:Any city or
TEMP.METER OR POLE INST.
� countywhlrA requirnapermittammWct,alMr,lmprove,demolbM1,orrepair
P .'Qri any stscturc prlorto ib lamsance,aleo requiretheappBcentlasucM1 penNt to I'OWFR DEVICES
6 g U file a signed statement that he Is licensed pursuant to the provisions of the /1
06Contnnofe License law KM er9(commentln ithSection 7000)ofDivi.
SWIMMING POOL ELEELECTRICt-30�GGn sion3ofthe Businessand Profemiom Code)orthatthebemmptthemfmmand VALUATION
C 52.a the basis for the alleged exemption. Any violation of Section 70315 by any 0[JfLEISBWITCI IFSFI%'fl1RF5
« applicant fora permit subjects the applicant to a civil penalty a nroom ore than
five hundred dollars($500). NEWRESIDENTIALELECTR SQ.FT. STORIES TYPE CONSTRUCTION
❑I,as owner of the property,or my employees with wages as their sole
7a compenutlon,wBldothework.and theatmclure is not intendedor offeredfor
O sale(See 7000,Business and Profmiom Code:The Contactors Liceme law
g does not apply to s owner of property who builds or improves thermn,and OCC.GROI RFS.UNITS
whodoneuchworkhmaself orthrough NsownemploymE provided thatsuch
improvemenb are not intended mattered forsale.IL however,thebullding or TOTAL:
Improvement kwldwithinoneyearofcompletlontbeowner.WflderwBlhave
th'Shrdenofpmvingthat he did not build or improve for purpose ePoale.). QTY. PLUMBING PERMIT FEEFLOODZANE APN
L„f L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(See 7074,Business and Profeasios Code:
Ilia Contractors Limns Law don na apply to an owner of property who ALTER-DRAIN k VENTWAIIIt(J5N
builds or improve thereoM and who contracts fee such pi jects with a FEE SUMMARY
cB[atlor(s)licensed pursuant to the Chowder's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Ser- B k P C for this reason
DRAINS FLOOR.ROOF,AREA,ODND. SANITARY Y N
Owner Date .. RECEIPT p
WORINIAN COMPENSATION DECLARATION FIX.Il1RE5[7:R 77tAls SCT-00L TA% Y N
I hereby affirm that I have• Insurance
a c o consent to op thereof ora RECEIPT N
rtl ate ofWorkeni Comperuratlsonlmurance ora certified ropy thereof(Sec. GAS F.A.SYSFFM.1 INCA OUTLETS PARK FEE Y N
3800,lab C.>ll� RECEIPT N
Policy M_ 4p(T— GAS EA.SYSTEM-OVER4(EA)
CO
BUILDING DIVISION FEES
ertNed ropy V hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
ertNed ropy V flied with the tlty Wpectlon division.
CERTIFICATE OF UEM PfSON FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.N1OFr, Date Recel t#
('chis section need rad becompleted If the permit V(Drone hundred dollen
I
($1mnifes.)nityma
that In the perfounce of thewk(orwhsued, WATER HEATER W/VENT/ELECTR ENERGYFEE Y N_
ich this permit le Is
I shall not employ any person In any manner an as to become subject to the WATER SYSTEM/TREATING
Workeri Compensation laws of California.Date PAID
Z 0
PP SQ,FE. Date Recei t#
NOTICE TO APPLICANT:If,after nuking this Certificate of&tlon,you NEW RESIDENTIAL PLMB.
should become subject to the Worker'Compensation provblom of the Labor TOTAL:
MN Code,you must forthwith comply with such provbius or this permit shall be
IL j deemed revoked. .1WILDING FEE
d CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency forthe perform- ELECTRIC FEE
Z ante of rhe work for whkh thbpermit le Lssaud(Sec 3097,CIv.C.) TOTAL:
U O lender-Name PLUMBING FEE
LLI— Landers Add n:-a - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE xQ7
OO Icenify that l have read this appllcition and Yate that the above Information
1 bcorreR.I agree to comply with all tltyand county ordinance and Yate laws PERMRLSSTIANCE FEES PAID:
>. fA relating to building construction,and hereby authorize rcpretentatives of this
H ED city to enter upon the above�mentkmed property for Inspection purposes. ALTER OR ADD TO MECH.(') Date RecCipt#— (We)agree to save,Indemnify an d keep harmless the City of Cupertino
ag.i.011abilifrs,judgmerthcmieandexpenaeawhich mayln anywayaccrue AIR HANDLING UNIT 10,000CFM) SUBTOTAL'
ag Id Clry noun era of the granting of this permit AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
��� 7 ,
i urs o(AppBcaHAZARDOUS
Data IXl-IAl1gT HOOD(W/DI1CT) CONSTRUCTION TAX PAID:
HAZZARDOUS MATERIALS DISCLOSURE /y�
Will the -fiedapplicant the ursmind buildingoavpa Code, h handle hazardous HEATING UNIT(TO 100,000 BTU) �[�. Date RCCeI t#
material as definedbythe Section 25532(a)?
!Code,Chapter 9.12,and the
Health and Safety Cade Section 1553](x)1 BEATING UNIT(OVER 100,00)BIN TOTAL: s�
Rill
��II
Y. t]No
hick sent Spplicentorfuontamibuilding
nts oceupantuse equipment or devices VENTILATION FAN(SINGLE RESID) Irjrjl�d KlYRiIATE
which emit hagem rat air District?
me as de0ned by the Bay Area At, `s,ll�
ality Management Dlstdtl7 BOILER-COMP OHP OR 100.0008TU)
Yn ❑Nu N (�t
hveread the hazardous materials requlrementsunderehapter6.95 of BOILER-CAMP(OVIR 100,000 BTU)
the California Health k Safety Code,Sections 2550.5,25533 and 25534.I
understand that if the building does not cumently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT. /silts g�
hapomlbllity to net lfy the ocanpart of the requirements which must be met
- prior to Issuance of a Certificate of Occupancy.
Owner or authorised agent Data TOTAL: ISSUEDBY:
OFFICE COPY