21570 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ea Identification 7 PER.MITNO.
Building Addreeo 21570
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d�a4 o114, �.t�a� Off�?1`7_j` CITY OF CUPERTINO-BUILDING DIVISION
,• Cort aaoraName: Lie.N. APPLICATION I PERMIT
BUILDING-ELECTRCAL-PLUMBING-MECHANICAL CATEGORY CONTROL N
Architect/Engines Llc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.,. PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby dk70 that) 11censed d( ,.nanc APT'LIANCESRESIDENTGL JOB DESCRIPTION
Incense I Section force 0l d effeon3o(the Businessand[arolesdona Code,and my I
hese.bin full force and effect. Ppm s 2,p 14L e-cl) w jtiLceo
Date G HITIE m UP TO 2DO ANTS
201-1OW ANT'S
ARCNIT be used DECLARATION OVEIt I000AMPS e-Q.FT.FLOOR AREA $/SQ.FT.
��qqvu aO ZpOC I understand my plain shall be used a public records.
k d U Licensed Professional SIGNSELECTRICAL
6<cce. OWNER-BUILDER DECLARATION
fii SPECIALCI2CUIT/M15C
W1,,, Thereby af(irnthatlam exempt fromthe Contractors License law(orthe
70 Q H following reason.(Section 7011.5,Business and Professions Code:Any city or TEMP.METER OR POLE INST.
coontywhichrequ4 aper tommtmMa)/cr,impmve,dem lgh,orrepair
anystm=mpriortoiisE ance,aborequirestheappBcentforsuchpermittu POWER DEVICES .
L° V Ole a signed statement that he is licensed pursuant to the provisions of the
3aContractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING IDOL ELECTRIC VALUATION
F,�OS sion3oftheluslnessand ProfessiomCode)orthathelsemmpttherefromand
4 the basis for the alleged exemption. Any violation of Stolon 70715 by any OUTLETSSWITCIiFSITXTURFS Z(9(!)C)„cb
O applicant for a permit subjects the applicant to a civil penalty of net moethan
Ff
Ove hundred dollars($500). SQ. STORIES TYPE CONSTRUCTION
GG11 NEW RESIDENTIAL ELECTR FT.I,as owner l the property,or he employee with wage as thele sole
C 7 a mpecc.704,Business wink and iom Code:
ehe Contot ractors
or License
Law
�$$ does not apply to an owner of property who builds or Improves thereonand OCC.GROUP RFS.UNITS
who does such work himself orthrough his own employees,provided thatsuch
Improvements are not Intended oroffered for sale ILhowever,the WIIding or TOTAL:
IQmc
proved issold within oncyearafcumplelion,the owner-bulkier w01 have
tWmen of proving that he did net wild or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
0 L as owner of the roe bT.00D?ANE APN
property, 70KBusicontracting with licensed PERMIT ISSUANCE
TheconContractors
construct the project cut apply
to an o and Professions Code:
The Contractors estLicense law don net apply tct an owner E property who
Wilds or Improve thmun, and who t.d.e. for such P.aj v with a ALTER-DRAINk VFM-WATER(EA)
�gpSfaaor(eexmpt urd Smto the Contraetora License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
DE FEES
I_j I r exempt under Sec B&P C for this rcnonOUTSI
DRAINS FLOOR,ROOF,AREA COND. SANITARY Y— N—
• Owner Date —1 RECEIPT N
N_
a RKMAN CO PENSATION DECLARATION SCIMOOLTAX Y_
r-11 hereby affirm RKMAN _that I have a certificate of consent to"If-Insure,m FD(.IVRFS PER TRAP a RECEIPT N
certificate of W.riuns'Compemudion lnsumnceora certified copy themof(Sec. GAS F.A.SYSIFM-I INCA OUTLETS PARK FEE Y N
'00,lab C.) —
Policy N S F.A. ECEIPT N
Com any GAA.SYSTEM-OVER B UILDING DI VI SION FEES
�CertlOed copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
Certified copy is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE7RAP PAID
COMPENSATION INSURANCE SEWER-SAFICTARY-SfORMEA 200FT Date Receipt#
(This section need net he completed if the permit is foror hundred dollars
(SIOO)orhss.) WATER HEATERW/VENT/ELECTR ENERGYFEE Y_ N—
I certify that N the performance of the wmk forwhich this permit is uunted,
I shall not employ any perarn In any manner so as to become subjectto the WATER SYSTEM/TREATING
Worken'Compemmtion Laws of California.Date PAID
O Z Applicant NEWRESIDENTIAL ELMB. SQFT. Date RCceI t#
Z O NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you
should become subject to the Wmrkeri Comperuation provisions of the Labor TOTAL:
SN Code,you=at forthwith comply with such provisions orthis permit shall be BUILDING FEE7 U�
lL F3 seemed revnkea.CONSTRUCTION LENDING ACPCY SEISMIC FEE
d zI hembyaffrmthzt them is a construction lendingagency forthe perform ELECTRIC FEE
Z ante ofthe work foewhlchthls permit isissuei(5ec.3097,Civ.C.) TOTAL:
U O Icnders Name PLUMBING FEE
h lander,Address QTY. MECHANICAL PERMIT FEE
LL MECHANICAL FEB
O I certifythat l have read thbapplicationand aatethrttheabovc information
O W bcorred.f egrce to complywlth all city and county ordinances and state laws PERMITISSUANCE FEES PAID:
} ll rclaling to building construction,and hereby authorlxe reprerntaives ofthis
F N city to enter upon the above-mentioned property fm inspection purpose. ALTER OR ADD TO MECH.
Z (We)agree to save,Indemnify an d keep harmless the City of CuFentonDate Raoeipt#
V Wt liabilities,judgments,mrts and expenses which may In any way accrue AIR HANDLING UN (TO 10,000 CFM) SUBTOTAL:
g rutasid City In roe quence of the granting of this permit. CONSTRUCTION TAX
B 'f„/, tue AIR HANDLING UNIT(OVER IO,DIO CFMI
Sig-,'
Ilcant/Cont or •C Date IXFIAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wil l the apptica of or future build Ing occupant store or hand le hazardous HEATING UNIT(TO 100,000 BN) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the -
Ilealth and Safety Code Section 25532(a)t HEATING UNIT(OVER 100,000 BTU) TOTAL: Ll VP
0Yns 1]No
Will the applicant or future building rampant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE.
which emit hamoclous air contaminants as defined by the Bay Area Air
Quality Maragemcnt District? BOILER-COMP OHPOR 100,000 BTU)
[RYean No '
ave read the hsrar�iousmaterialsrequirements under Chapter 6.95of BOILER-COMP(OVER IW,OWBTU)
the California Health A Safety Code,sections 25505,25S33 and 75536. I
understand that if the building doe net currently have a tenant,that It is my NEW RESIDENTIAL MECIL SQ.FE
responsibility to naily the occupant of the mclWoment,which at be rat a V f{ 79Qo
prior to issuance of a Certificate of Occupancy. 1 r7
Owner or authorized agent Date ISSUEDa" 1
TOTAL:
OFFICE COPY