21729 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prosect Identification PERMIT NO.
Building Address: 21729
�L<f 3IIzT 7-5-6 �n/E i3Icvvlz C_7— Ln r— 36
Owners Name
4j r6o2 G/.°CU/° one. CITY OF CUPERTINO-BUILDING DIVISION A
Contracto/u Nrmec - Lm.No: APPLICATION / PERMIT
/3 VS o o 77 BUILDING-I].F MCALPLUMBING-MECHANICAL CATFC,ORY CONTROL 0
ArtM1lt ct/Fsglneer. - �Lle.Nix
SAN/ n/ L A Go ro QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERh4TISSUANCrlvf
E
LICENSED CONTRACTOR'S DECLARATION X
[A
I hereby affirm that lamhe...ed under provislonsaf Cha per 9(..an. APIUANCES-RES[DEN'ML JOB DESCRIPTIONingwith5ect1on7000)of Dlvlslm3 ofthe BuelneseanddPPmfcaslonaCode,and my
Limnos Clanll�,Llc.� '51�00 / 7
PANELS G✓L
Date Contractor S�
ARCHITECTS DECLARATION 201-1000 AMPS
rc0 7 !undentand my plain shag be used as public remnla OVER 1000 AMT'S
SQ.FT.FLOOR AREA 5/SQ.FT.
O
yy Z Licensed Professional SIGNS ELECTRICAL -/
<<wui OWNER-BUILDER DECLARATION
rii ET
Thereby a(firmtktlamexempt(romthe Contracto/s Lkense Lwlorthe SPECIALCIRCUIT/MISC
followingrthrect tresap 7W15,Business and Pro(eselona Cade:Mydty or �r
O _F TG6P.METFR OR POLE INST. Sp'j -91
FAQ cwntywhlch mqulrnapermitromrutrud,alteglmprove,demolbh,arrepalr
anystructurepdartoltslnanme,abortqulrtetheappllrantfonuchper tto POWER DEVICES
file a signed statement that he islicensed pursuant to the provisory of the
O u. Contractor's License Law(Ck 9(conurcncln Ith Section 9000)of Dlvl-
3O� per gw SWIMMING POOL ELECTRIC
son3oltheBusinessandPnefesebmCode)orthalhebeaempttherefromand VALUATION
the basis for the alleged exemption. Any violation of Section 9mt5 by any OUTLETSSVRCHFS
appllcadtfars permit subjects the applk:ant to a civil pensltyd nofinek
retn / a
'c. five hundred defiant(S500).
7�n ❑I,as owner of the roc NEWRESIDFMIALE TR S =CONSTRUCTION
e property, their ` V —
compensa0KBusdothandPrandlhesWdumh Contendedo te..Law
O d for C
sale tnor apply
to ainowess andf property
Code The orimpcto/s Lenon Law
does ho ocasucly torn owner dp rough who nempoy mprmestknmRand such I -CEAROUP RES.UNITS
F' wprovementsam not Intended
orthwghhlsowneffemd .If,ho n,provldedthaigor
Improvements<rtd withindedoroofcomplelo.theh evbullderwilIer,the have PAT9 TOTA
improveen of hyoidg than he didoneror build
uil pldlon,rove foenbullse ofsaicrve '
ttLj Lanwner of the property,
am exclorimpmveforing with licensed
Q7y, PLUMBING PERMIT FE
Ltr I,as owner tr the Property,am exclusively Bust contracting with Thence, FLOOD NE AIN
mntndors to comtroRthe project(See 9W�,Buslnm and Profesbrs Cade: PERMIT ISSUANCE
7FM1e Contmc oes License Law don not apply to an owner of Property who ALTER-DRAIN k VENT.WATER(EA)
Wilds or Improves thereon, and who contracts for such ptu)eets with • FEE SUMMARY
c��aI.Tn
actor(s)licensed pursuant to the Contmomes License Law.
ff I am exempt under Sec. B&P C for this reason I BACK FLOW PROTECT.DEVICE OUTSIDE EES
DRAINS FTAOK ROOF,AREA,COND. SANITARY Y_ N_
• Owner Date RECEIPT
WORKMAN COMPENSATION DECLARATION FIX.HJR6S PER TRAP SCHOOLTAX Y_ N_
F11 hereby afllrm that I have a certificate of consent to self-Imum,or RECEIPT Y
certificate of Worken'Competsatlon Insurance or a certified copy themoft$ec. GAS EA. INCA OUTLETS PARK[-6 Y N_
380,1<b C.) RECEIPTNY
Lo
Y _ .O GAS.F.A.SYSTEM-0VER/IEA)
Cam env U ya e b fmi Tom/ GiG BUILDING DIVISION FEES
copyv hereby famished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
(Rl Certified mpybfiled with the city inspection division. _ - r
CERTIFICATEOF FJ(EMPTION FROM WORKERS' GREASETRAP PAID _
COMPENSATION INSURANCE SEWF3t SANTTARY-SIORMEA.200FT. Date Recei t
Rials section need nd k completed If the permit V foram M1undred dollen
(5100)orlmJ
WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I¢ri that Nthe performance of the work rorWMCM1 this permit la issued,
1 shall not employ any person in any manner so as to become sub)ed to the WA=S,ST�/TREATING
Workers'Compansadon I<We of California.Date PAID
O Z Applicant NEWR RESIDENTIAL PLMB. SQFF. Date Recoi t#
Z O NOTICE TO A1suLICAtothe ger makinra'Co Comhis pensation
cate provi. er,of the
Labor
F ske,you=uld a subject to co Work en'such prsatlomorthlomrmit s Lab be TOTAL:
S y Codeiedmocs[forthwlthcomplywith suchprovtsiomorthbpermltahallbe BUILDING FEE C',
W > dnrtN revoked. -
M0. I] corvsrgurnory Lwmrvc wcEJacr SEISMIC PEE O
Ihemby affirmthattthem bacomtroctlon leading agency 30W,Civ.
C.) perform ELECTRIC FEE - '
0 Z rnceerthe.N.mek for which this perM[bbsued(Sec.3092,Civ.C.) TOTAL°
LL O 1<nder:Name PLUMBING FEES-
ly U knaer'iAddnm QTY. MECHANICAL PERMIT 1'GE MECHANICAL FEE d
O O Imdlfyth met.cma lywith alintya.Mmtethattheaboveld st.tchm
1 slating bulidig mmplywBb anll dtyandcountyiza representatives
stateTaws- PERMIT ISSUANCE F
>. 0.
city tingrobupongmabo,t, entiondpropetyfeei<rtpnsenpurposs.
F. Z Alyto )aenter
ee to sac,Wvermentl an
property(nimpe Cit purposes. ALTiRORADD TOMECH. Data Reeeit#
_ (We)agree to save,IndcmNtts and keep es which
the City of Cu pert Ion P
against said Cin,pdgmequencetund expenses which Fermat anyway amue AIR HANDLING UNIT(7010,000 CFM) SUBTOTAL:
against arld City m consequence of the granting of this perm'.
AIR I{ANDUNc UNIT(OVER lo,twcnd) CONSTRUCTION TAX
r A `Ic�.r \11
Is
t C N TR CTION T X PAID:
Slgwture o(A pll AZAR DOLSor Date EX}IAUS'T HOOD(W/DUCT) 2 0C.6
HAZA RDOUS MATERIALS UISCLOS R �y '1/ Q
Will the appEca at or by the
turcrtinra ng oecupant sde, hband lc hacardom HEATING UNIT(TO 100,f1008N) Date Recel t#
I halt al as defineddode Cupertino MunidpalCode,Chapter9.II,and tM1a -
Iicalth red Safety cmc Section 75532(a)7 HEATING UNIT(OVER 1W,000 BTU) TOTAL:/ e S'
❑Ycs �]No
Wllltheapplicant or future building occupant use equipment ordevices VENHIATIONFAN(SINGLERFSID) 16.SUAN-E DATE
which emit ha unJous air coetaminants as defined by the Bay Area Air R.'�J
• Quality Management DistrlR7 BOILER-COMP OHP OR 100,000 BTU)
Yas No p
havercad salt�oet most,Se requirements 533 ordplcr er o1 BOILER-COMP(OV6Il W,000 BTU) p 1, 4 1991
the er rand h Health buildingthe Sfety Code S t Curr 25505,ve a t and 2553!. I
undentand that notifyteocu ant of the currentlyhavewhich
that it mot NEW RESIDENTIAL MECH. SQ.FI'. ^
responsibilityriortro of afCehcicmpamdtpancy.requirements which nwst be erre[ sIse pat,,,., ,
prior to L+suancc o!a Certificate of Ompanq. a 1es'
Owner or authoriked agent oit, TOTALISSUED B�
:
OFFICE COPY