21475 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project identification I ?F %IITNO.
Building Addmsa' 21475
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1 Co /�'49R[� 02 S2 31yr CITY OF CUPERTINO BUILDING DIVISION
Cancra '.Name Llc,Ncx APPLICATION I PERMIT
Ti0 BUILDING-¢ECTRICAGPLUMBING, E HAMCAL CATEGORY CONTROL N
c i ea gineen LIc.N.
,QTY, ELECTRIC PERMIT FEE - BUILDING PERMITINFO•!• «.
Address PERMITISSUANCE �2 00 ® F111-1
❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Iherebyaffirmthat l amlicensed under provisions of Chapter9(dame,- APPLIANCESRPSIDENIIAL JOB Uu ON
Ingwith Section 7000)of Divlslon3olthe Businesand ProfeslonaCode,and my
AMmR
I b In four dfd`t �a PANELS 1. \ Aar/
LlcenseC�LICN aL r SC�)-eeV� POl IVU
Date_/� �Conmador /p
ARCHITECPS LARATION / OVER00hMPS K
AM
ccI understand my plana shag be used as public records. SIGNSE ECT SQ.FT.FLOOR AREA 5/EQ.FT.
O
G�
Licensed Professional SIGNS ELECTRIC
�<y OWNER-BUILDER DECLARATION SPEC4CIRCLjWISC
Z IherebyafBrmthitIamexempt fromthe Contractor's Lleenxhwlorthe
Ei following reason.(Section 7031.5,Business and Professions Code:Any cry or 'I1iMP. R ST.
county which requires a permit to construct,titer,improve,demoLLsh,or repair
11 any stmdure prior to it,issuance.also requires the applicant for such permitto CF5
K file a signed rtatement that he b licensed pursuant to the provis of the p
SOS Contmcors License Law(Chapter 9(commencing with Section 7000)of Divi- NG EL C V/ VALUATION
OS gon3ofthe Bugnesand Pmfmior Codc)arthathebexemptthemfromand s A
-• the basis for the alleged exemption. Any violation of Section 7mI5 by any OUTLETS TC fl 1 S O v D 0
O apph..tfo,.pdrediabjeRstheapplicamtoativil pemltyofnd morcthan
five hundred dollars(5.500). NEW RESIDENTIAL ELECTA SQFp. STL)KIES TYPE CONSTRUCTION
- .. ❑1,as owner of the property,or my employees with wages as their sale
7 compensation,will it o the work and the stmadre in not Intended or offered for
tCC sale(Sec7064,Busimevand Profialom Code:The Contractors Llceme Law
cS does not apply to an owner a property who builds or improves themon,and CCC.GROUP RES.UNTTS
who does such work himself orthrough his awn employees,provided that such
Improvements are not intended or offered fee sale.If,however,the building ce TOTAL:
Improvement is sold within one year of completion,the owner-builderwlll have
thbunters of proving that he dident build or improve for purpose of sale.). QTY. .. GPERMIT FEE" FLOOD ZONE AIN
M L as owner of the property,am exclusively mntrating with licensed EI MIT M16ANCE
centnrs doto artstroct the project(Sec 7044,Business and Protest..Code:
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN NEM- (EA)
build. or improves thereon, and who contracts for such piapers with a ')
m,,11Ltt���adorts)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEV11 ''.rob .rFEE_$UMMARY;'7,.
u 1 am exempt under Sec A B 6 P C for this reason
SANITARY Y N
Owner Date DRAINS.FLOOR. ]iEA,GOND. RECEIPT#
WORIUMAN COMPENSATION DECLARATION F1Xft1RES-PERTRAP SCHOOL TAX Y_ N_
❑I hereby affirm that I have a certlRote of consent to self-invm,or
RECEIPT N
certificate ofWarkeri Comperuationlesurance or a certified copy thereof eid. GAS F.A.SySFEM-1 INCA 01 PARK FEE Y N
3800,Lab C.) 9��p/ 90 RECEIPTI
PoliryN —- GAS EA.SYSTEN-0VER4(EA) BUILDING DIVISION FEES
Camp Cy ri
I ICertrled copy is hereby filed
the city GREASE/INDUSTRL WASTE INTFRC PLANCHECK FEE ifs
rN�i Certified ropy b Bled with the cry wpetfon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANCCARY-STORM EA.200FT. Date Remi t#
(This sedion need nor be completed B the permit Is foroim hundred dollars
(s)m)or lea.) WATER HEATER ted/VENT/ELFOTR ENERGYFEE Y_ N_
I certRythat in the performance of the work for which this permit is Issued,
I'hall not employ any person in any manner as a to became subject to the WATER SYS /TREATING PAID
Worken'Compensation lawsof California.Date
Q Z Applicant VMECHANICAL
B. SQ.FT. Date Real t#
Z O NOTICETO APPLICANT:ILaffor making this Cereliate of Exemption,you TOTAL:
should become subjed to the Worken'Compenuallon provision,of the Labor
I— (n Code,you most forthwith comply with such provisions or this permit shall be BUILDING 1 0
� j_ deemed revoked. SEISMIC FEE
W CONSTRUCTION LENDING AGENCY
(L Hideby.fil that them Is a construction lending agency for the perfoeryTOTAL: ELECTRIC FEE
Z anceaf the workforwhkhthb permit is Issued(Sec.3097,Civ,CJ PLUMBING FEE
() O Lender.Name r
LL Lenders Add—,. •PERMIT FEEOW ImtlfyBailhavereadthbapplicaHan..damtethethnaboveinfarmaticn turret I ageelocomplywithall cityand countyoddleance.and gate laws
Y QL elating to building construction,and hereby subutu representatives ofthb
F in city to enter upon the above-mentioned property for Inspection purposes. ALTFRORADDTOMECH. Date Rxeipt#
V _ IWO agree to ave,Indemnity an it keep harmlea the City of Cupertino
against liabilities,judgments,coegsand expenswhich may In any way accruAl HANDLING UMT 8010,000 CFM)e SUBTOTAL:
against Try In come ace of the granting of this permit./ /_ CONSTRUCTION TAX
CONSTRUCTION TAX PAID:
y���-` AIR HANDLING UNIT(OVER t0,000CM)
SfErum al Applicant/Contra o, Dat EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE FIEATING UMT(TO IOO,000BM
Will Neappllcantar future building occv pant store or handle havardous Date RCCCI t#
material as defined by the Cupertino Municpal Cade,Chapler 9.17,and the
Health and Safety Code Section25532(a)? HEATING UNIT(OVER 100,000BTU) TOTAL:
❑Yat [i]No VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which
emae applicant or r cont building as deft n d by equthe Bay nt Area device
Quality anagement iitnct? nano as defined by the Ray Arca Air BOILER-COMP CHIPOR 100,000 BTU)
Quality Management Dlstcct7
Yes No
have read the Foss ous ryem
teriab requirements under Chapter 6.95 of
BOILER-COMP(OVER 100,000 BTU)
the California HaBhh Surety Cade,Sections 25505,2s533md 25534. 1 '� I11'J
understand that it the building does not currently have a tenant,that it is my NEW I4LSIDEN7IAL MEU i. SQ.Ff. -
mspomibilitytonotifytheoccupantoftherequimm nta whkh mu
Prior nceofa Certifica do cupart . Cl/�
`r`s`� l
17 2l v
neoor�riud agent `r`s Date I55LTiD BY: ` C �rV-�-C-
TOTAL:OFFICE COPY