21431 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO,
Building Add...:koQej@ 21431
Lnvear. .me: one:
-j9S—$3Z0 CITY OF CUPERTINO-BUILDING DIVISION 1 .JS `D — — O
C tndore Name:
UC.N. APPLICATION /PERMIT CIt
BUDING-ELECTRICALPLUMBINC-MECHAMCAL CATEGORY CONTROL
R. Y
Archinct/Englker. Lie.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addedu:lO)OaSk. PERSUTISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hth Sedion7OOhallam.im3ofthe usir andp ffe am r9(mmmmc- MPUANCESRESIDEN7IAL DESCRIPTION
In ..i.cct1on7000)of defiedn3ofthe Buelnnaand Pro(cuimaCade,end my a ATe n
Limsets In full110 a deflect PANELS
License 1 C LIe.X
Dale O Conmada�r � III!IQ 2DO AMPS
ARCHITECTS DECLARATION 701-1000 AMPS IN
q�u Q CO I undemtand my plans shall be used u public records. OVER IODO AMPS SO.FI.FLOOR AREA $/SQ.Fr.
k I u Llmnaed Professional SIGNSELECTRICAL
rn<QLFA OWNER-BUILDER DECLARATION SPECGLCIRCUI LSC
Zn, �q Ihereby affirm that l amexempt from the Contnctora License law fee the //
09 P❑ following Hawn.(Section 70115,Business and Profession.Code:My city or TEM MLTtAOR
K I"' muntywhich requiresa permit reconstruct,alter,Improve,dennibh,or repair
a� anystrocture primtolb Wuawe,aborequl theapplicant(msuch permltto
R file a signed statement that he Is Rcense l punuem to the provisions of the DEVICES
6Q 951r,� Contrad.e.Lie..Law Chapter 9(mmnendog with Section 7000)of Divi. NG PQOL CfRI
SOS sion3ofthe Bu.nn.=d Profmss mCode)orthathebemmptthemfmmand VALUATION
Othe Web for the alleged nemption. Any violation of Sedhm 7005 by any O TS-SWqk46-FI6JR1S
Me?c eppRmntforapermltsubledstheapplicanttoadvilpemltyofna=mtWn
$ flvehundred dollars(SSOB. NEW D AL L TR SQ.FT. SIORICS TYPE CONSTRUCTION
�n �i,as owner of the property,or my employees with wages to their wk
compensation,will do the work,and the structure is not intended or offered for
q
In(Sec.70K Business and Professions Code:The Contractors Llmnso Low
$$ docs not apply to an owner of property who Wilds or Improves thereon,and OCC.GROUT' R'S.UNITS
whodoeseuchwork himsalfmthrough hisown employees,provided thatwch
Improvements are not Intended oroffered tweak.If,however thebuildleg m TOTAL:
improvement bsold withlnone)earofcomplMbmtheowner-W Rderwillhaw
t rdertdprovinglhathedld net build or Improve for purpose ofsale3. QTY. PLUMBING PERMIT FEE FLOOD TONE APN
L as owner of the property,am exclusively mntrading with licensed
mntracton to mestmd the project(Sec.70K Business and Professions Code: , PERMIT ISSUANCE
The Contractor's License Law done net apply to an owner of property who ALTER-DRAIN k VENT-WATER MA)
Wrecontracts builds or Improves thereon, and who contfor such p(okds with a FEE SUMMARY
INam
licensed pursuant to the Commences License Law. BAIX FLOW PROTECT.DEVICE
am exempt under Sec max
on k P C for this rean
QIITSIDFFE=S
DRAINS FLOOR ROOF,ARRA,COND. SANITARY Y_ N_
Owner Date RECEIPT Y
WORKMAN COMPENSATION DECLARATION PER TRAP SCFK)OL TAX Y N
hereby affirm that I have a certificate of consent to self-loan ):p(]1/Rpg
,ore RECEIPTNY
certificate of Workers'Compensatlonlnsunnce ma certified mpythemof(Sec. CAS EA.SYSFFM.1 INCA OUTLETS PARKFEE Y N
3X00,lab CJ
I'ollcyY 11S��X13 BUILDING DIVISION
GAS EA.SYSTEM-OVER 6(EAJ
Cam env � ❑p tlU1LU1NG DI VISION FEES
Cc copy is hembytumecity GREASE/INDUSIRL WASE INTERCEPTOR PLANCHECKFEE
IGICerllfled copy b filed with the city inspection division.
YY
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEyyER-SAN FARY-STORM EA 700FI Date RCCCI [#
Ghls.ectbn need not be completed Bthe parent b fee hundred dollars
(5100)or less) WATER HEATER W/VENT/ELECTR '�•� ENERGYFEE Y N—
I mrtlfythat in the perfomunmof the work forwhlch this penult is Issued,
I shall not employ any person In any manner w as to become subbed to the
0WATER SYSTEM/TREATING
Workers'Compensation laws of California.Date PAID
Z NOTICApplicaE
Z Z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIALPLMB. SCI.FI. Date Recei t#
H should become subject to the Workers''Compewtice provisions ofrhe Labor TOTAL
cc — Code,you moat forthwith comply with such provisions orthb permit shall be BUILD
ING FEE
W 7 deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
0. Iherebyafflhattleemis construction lending agency forthe perform ELECTRIC FEE
D Z arm ofthe workfor which thbperndl he Issued(Sec.3097,Civ.C.) TOTAL:
O O 1<nder'.Name PLUMBING FEE QQ
IL F Lender.Addnu QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I comilythat l have read thlsepplicatiunand sntethatlheahovelnformatlon
C Is turned.l agree m comply with all city and countymclinancesand Mate laws PERMIT ISSUANCE FEES PAID:
r 10 relating to building matructi°n,and hereby authorise representatives of this
F Z city to enter upon the above-mentioned property for Wpedion purposes. ALTER OR ADDTO MECH. Date Rfefl [#
V — (We)agree to save,Indemnify an d keep harmless the City of Cu penton
against llabllltlms,pdgments,mate and expenses which may In any way accrue AIR HANDLING UNIT(To 10000 CFM) SUBTOTAL:
aga Wt old Cll In ronsequenm of the granting of this permit.
C ^� X \•�S, U AIR HANDLING UNIT(OVER 10,0D0 CFM) CONSTRUCTION TAX
Signatnreof Applicant °ntractor fY Date EXHAUST HOOD(W/D1KD CONSTRUCTION TAX PAID:
HAZARDOUSMA ERIALSDISCLOSURE
Will the applicant or forms building occupant store or handle havardous HEATING UNIT(TO 100,000 BT1p
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the Date Recei t#
Hcalthand Safety Code Ion 75537(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: 0
yesNo
Wllltheipplimet m fu rc Wildingar pamuuryuipmentmdevlm VENTILATION FAN(SINCLE RFSID) ISS TE
which emir havardoue air contandra s.a defined by the Bay Area Air
Quality Management gQbtr�{�ctt7 BOILER-COMP DHPOR 100,D00 BTU) n��
4
yes, o Fe d 19�J
have mad lheha see matedab requlremenn underCM1apnr 6.95 of BOILER-COMP(OVIR 100,0000TU)
the CallfmnW 11e.Ith A SafetyCode,Sedlons 75505,25533 and 75539. 1
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FI
responsibility to notify the occupant of the requirement.which must be met "`CrI NY `I
prior to Issuance of a Certificate of Occupancy. wt. -TY
h - Radios 1a -S -Cla
Owner or au orlmd agent t3 pate
TOTAL: ISSUED 6Y:�
OFFICE COPY