21535 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro cc,Identification PERMITNO.
Building Address: �l�s 21535
a (/��8 CITY OF CUPERTINO-BUILDING DIVISION A�^^ � N 1 A
APPLICATION / PERMIT 1 rJ'l l
�t No
BUIL.DINGS.F-CTRICA4PLUMBING-MECHAMCAL CATEGORY CONTROL N
� Amhited/Engineer. Lic.NNo:
�y�,s �--,.• ,, l (�� < � QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address r 0 `+�! C.E.LU-�c1PERMITISSUANCE rJ7i
LICENSED CONTRACTOR'S DECLARATION El 1:1 El 2S
Iherebyaffirm that l am licensed under provisions of Chapter9(comrome. APPLIANCESRESIDENTIAL JOB DESCRIPTION
ingwlth Sed1on90(0)hf Division3 ofthe Buslnessand Profeslon.Cods,and my
license 1.i II�A2d died. C�� PANELS
CJ
License la Contractor
UP TO 2DOAM
Date Conlnctor_-.� 201.1000AMPS '
ARCHITECTS DECLARATION OVER I000 AMPS SQ.Fr.FLOOR AREA 5/SQ.FT.
gyppP++00 L I understand my plan shall be usM.public recoris
k O Licensed Profesioml
cid SIGNS ELECTRICAL , n (^ B N
a< OWNER-BUILDER DECLARATION SPECIALCRCUIT/M]SC ` "
Z f-�(-.�a I hereby owingrafOrmtlutI son on7031mptlromthed Professions
sCode:License Any
for the - I .� r.--, UTE R
p lollowingreasen.(Sesa permi1$Buaines and Proprove, Code:Mycityor - f 10�/ g6—�
O Z I-.9 TEMP.METER OR INST.
F muntywhkh requbesapermittoconstrud,alien Improve,demallahorrepair
anystrunum prlorm its dsuance,also require the appbant forsuch permit to POWER DMC
q�
EFa O file a signed alalemeLaw
that he le r 9(even pursuant it the proallona of the
Con 3 oftha LlcemeandPunapalonsCm)orthatderring with xompthernfSection 7")of andivi- SWIMMING LELECTWC T10N
F+wO< eion3o(thh8uslneesand Pro(eslomCode)orthat hetiexemptthercfromand
the basis for the alleged exemption. Any violation of Stolon 90315 by any OUTLE TCHESFIXTURES
�<n appu.nt fora permit subjects;theappucanuo.civil penalty visa morethm
r. five hundred dollars(SM. NEW DENTIAL ELECTR FT.
c ],as owner of the property,or my employers with wages as their sole _SQ.FT. 6 TYPE CONSTRUCTION
<, ompen.etNo wu ine...workandtheswce:The mlnlendedoroffse Lfor
Q sale(Sec. ppy to abiessandf property
Code The Contractors License law
3� whoa does
apply loan owner ofdproughhis o nem oy mproveted thaton,and OCC.GROUP RFS UNITS
whodoessuch work himself a moths edsownemployee,provldedthatsuch
improvementsarerotintended thebuilding or have TOTAL
i provement haold within orayearofcompletlon,toe owner-buuderwillhuve
th�h +rden of proving that he did not baud or Improve for purpose ofsak.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
Lj L as owner of the property,am exclusively contracting with licensed 17ERMTTISSUANCE
contractors to construct the project(Sec.90K Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who
Wild,or Improv.thereon, and who contracts for such p0ojecb with a ALTER-DRAIN&VENT-WATER MA)
cu tt{actor(s)licensed pursuant to the Contractor's Limme Law. FEE SUMMARY
If am exempt under Sec B&P C for this reason BACK FLOW PROTECT.DEVICE
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,CONE). SANITARY Y_ N_
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION FIX.IURES PER TRAP SCHOOL TAX Y_ N_
I hereby fitthat I have a ceniBate of consent to self-Insure,or RECFII''1'N
irate of Worken'Compematlonlmurance ora certified mpythemof(Sec. GAS EA.SYSTEM-1 INCA PARK FEE Y N
3800,Lab C.) -li wj r sin�y ��s7 // RECEIPT
Policy (lL IN�-I- �7_/ GAS FA.SYSTEM-0VER )
Com sato ST.1.21:T'l Of -� BUILDING DIVISION FEES
Cenified cup hereby furnished. GREASE/INDUSML ASIS INTERCEPTOR PLANCHECK FEE
Certified copy b filed with the city impCed0o division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SA y-STORM EA 2f10FT Date Recei t#
(1'hlssectihs need not be completed if the permit isforom hundred dollars
($100)or les. WATERTOTW/VENT/ELECTR ENERGYFEE Y_ N_
- Icertlfy that In the performance of the work for which this permit is Issued,
I shall nm employ any person in any manner so as to become,Minted to the W SYSTEM/TREATING
Workers Compensation Laws of CaIIfomia.Date PAID
O Z NOTICApplicaE R19DFNIlAl['LMB. SQFT. Date Remi t#
Z O NOIlCETO MPL[Gto the after rs king Compis ensation
prteof Exemption,you
Pshould become subject to the Workan'Campenaatlon provialom ofthe Gbor TOTAL:
CC N Code,you most forthwith comply with such provisloruorthis permit shall be BUILDING FEE
W j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Iherebyafflrm that there is a construction lending agency for the perihre, TOTAL: ELECTRIC FEE
Z once of the work forwhichthis permit VL+sued(Sec.3099,CIv.C.
O O Lenlce.Name PLUMBING FEE
LL Under.Addre. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I.dlfythat l have mad this applimthmand statethatthe above information �^Y
coma,l agree to comply with all city and countyordinascesand state Jews
PERMIT ISSUANCE FEES PAID:
} N relating to building construction,and hereby authorize representatives of this
H Z city to enter upon the above-mentioned property for impedlon pu roses. ALTFRORADDTOMECH.
�tind,=ify an d keep harmies the City of Cupenlno Datc Receipt#
agaisandeapenseswhlehn In anywayaame AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agaiof the granting M t�p 1{..,, ,s,
' V`j AIR HANDLING 11dTT(OVER IO,000CFM) CONSTRUCTION TAX
Signature of Appliant/Contractor I Date IXHAUSTFIOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS Of SCIOSURE aa,,Z��
Will the a ppuont or hold re building occupant store or hand In hazardous HEATING UNIT(TO 100,"BTU) ,fJv Date Recei L# 11
material as dented by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(a)T HEATING UNIT(OVER 100,000 BM TOTAL: t
❑ Yen M No
Will the applicant or future building compact useequipment ordhvices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILFR-COMP OHPOR 101,0(10 BTU
4Yea ❑No �Q
havcrcadthehavrdousmateriabmquirementsunderChapter6.95of BOILER-COMP(OVER IW,000 BTU)
the California Health&SafetyCode,Sections 25505,25533 and 25534. I
understand that if the building does not curmntly have a tenant,that it is my NEW RER DEM1AL MECH. SQ.FT JUN p•8 0fSp1
repMp�bllit�y m notify the oc.p.at of the requirements which must be met s8 c+
priofpb]slya nce of a Comficate of Occupancy. 1NjN.,
Owncrhr authorised agent Date ISSUEDBY: v
TOTAL:
OFFICE COPY