21750 PPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Build].,Project Identification U x G PERMITNO.
Building Address: 21750
I \ \ 2)3 1,, P1�.L g-Loy- C��� pLraU � �L��
ante. one: A A A
CITY OF CUPERTINO-BUILDING DIVISION
Conhacu,'a Namc: Lie.No: APPLICATION / PERMIT
6-4300 17 BU1LDINGELEC1RICA1PLUMBINGMECHAMCAL CATEGORY CONTROL#
Archlted/Fsginser. Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address - PIMMITISSUANCE r1/
LICENSED CONTRACTOR'S DECLARATION I.-J✓ l�i
I hereby sit that lam licensed under provision. fCh.pter 9(commenc APPLIANCE°iRESIDENTIM, JOB DFSCRn'IION
Ing with Section 700D)of Division 3 o/the Businesand Profealon.Code,and m
limn.e b In s (orae and dfect. PANELS
License Clas 1 ontr for Q'Y
Date Contractor
ARCHITECT'S DECLARATION 201-1030AMPS
0 20 l understand my plans.hallM used as public records. OVERIn00AMPS SQ.IT.FLOOR AREA $/SQ.FT.
Q5 U Licensed Pr°fessiorul - SIGNSELEC]RICAL
< OWN-ER-BUILDER DECLARATION t�
I-n Fd SPECIALCIRCUIT/MISC
Ihereby affirmthat lam exemp from the Contractori License Law(orthe
oo following reason.(Scctlon7m1.5,Bmines and Proferlon.Code Any dty or 2
OZ^ county which requires a permit tommtruct,alter,nn h P ]TRIP METER OR POLE MST. U
F prove.demoib Dere air
Y .a anystmctumpebrtoluumancgaiamcruimtheappbantforsuchper it POWER DEVICES
K d file a signed insentient that he b licensed pursuant to the provisions of the
Contractor'sLicense Law(Chapter 9(commencing with Section 700D)of Div[- SWIMMING POOL ELECTRIC VALUATION
O sion3ofthe Businesand ProfmloneCode)orthat hebexem therefromand
6 ted beau far the alleged exemption. Any ,violation of Sectiont7m1.5 by any OUTLE755W17CHFSH%]URES
applicant fora permit subjects the applicant to dull penalty o(na nnmthan 1 Ck 4 I S q c,
c, five hundred dollars%51KE.
1,as owner of the my employees with g NEW RESIDENTIAL ELECTR SQ.FT. STORIES T1'PECONSIRLCTION
7< ❑ property,or tm 1 ihen es as there sole
compensation,will1.O.an orh,and toes C dere u not intended or offered for
' ❑ dole(Sec.pply to
dfpropety Code:The or improves
License Law
does( +� who not apply torn owner of throng hisobullds mpIcymproovidedthereat,
tsuch OCC.GROUP RES.UNITS
0. whodmsuch work MmseUorlhwgh hisowne.Ifhowevertiebuildingor
Improvement arcnot Wendedorof/cc pleio.th inner-q Lder ilI have TOTAL-
improvement useld withlnoneycarofcomplmiagthe owner-bunderwlll have
i"rdenof provingthat he did not bund orimprove for purposeofde.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively=trading with licensed PERMIT ISSUANCE
contradors to construct the project(See.7074 Business and Professions Code:
'The Contractor's License Law don no apply to an owner d property who ALTER-ORAL - A
beIlls or Improves thereon, and who contracts for such pppce,with, FEE SUMMARY
c'q�t[aetoRd licensed pursuant to the ContradMs License Law. BACKFLOW RO C.
LJ I am caemp under Sec. 8 4 P C for this reason
I DE FEES
DRAINS R F NITARY Y_ N_
Owner Dae REC #
WORKMAN COMPENSATION DECLARATION p0(NRES PER TRAP 1001,TAX Y_ N_
❑1 hereby affirm that I have a met ficate of consent to sell-inmro,ora ! RFLEI T#
mnificateofWorken'CompmatlonlrouranmmamAlfWmpythemof(Sec' GAS EA.SYSTEM-]
3800,Lab C.) PARK Y_ N_
Policy# GAS EA.SYSTEM-OVER#(FA) RELm'T#
Comanv l IJ . a-rn eaa.♦F 1. BUI LDING DI VI SION FE FS
Cert[f[ed ropy at filedthecity GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�Cen[/ied copy b here withth famished.
inspection division.
CERTIFICATE OF EXEMPTION FROM WORKLRT GRE ETR# PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200Fi' Date Re IpO lS.So
(Thusection need not be completed if ted permit It forone hundred dollars
($10))or tes.) ENERGY FEE Y N
I mnify that In the performance ofthe work for which this permlt a domed, WATER HEATER W/VENT/ELELTA —
I shall not employ any person In any manner se as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
z Z Applicant NEW RESIDENTIAL PIM3. SQ.FT. Date ReCej t(!
Z O NOTICE become,
APPLICANT:to the
after making thbs2tionCertificate
pro is Exemption,you
shoulddou Iforth mthe Workers'such EnuatinpmWis pmet slab be TOTAL:
I- N Ceconedr It forthwith comply with such provisloro orthu permitshall M BUILDING FEE
� j deemed revoked.
LU
O CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z Ihercbyaf(Irmtlut therebamtutmctlon lendingagenry forihe perform TOTAL: ELECTRIC FEE
7 ince of the work for which this permit is issued(Sec.30 Y/,CE,C.)
02 minder'.Name - PLUMBING FEE `1 a,
LL lender.Addres. QTY.I MECHANICAL PERMIT FEE MECHANICAL FE E
O W Imnifyihatthaecmdthuapplicatbn.M mtcthattheaboveinfornution
bcorrect.building complywnh and tyaMcountyoemprmsand statelasys I'ERMRISSUANCE (
} N city to globuilding construction,and he rebyauthodaepediontativesofthis l�---
FZ city to )aenter
ee to save,
aned propertylWpect it purpose. ALTER ORADDTO MECH.
_ (Vdq agree to nave,IMemnits and keep harmless the City of Cu accrue Date ReeciptElf
against said Ciegpdgmenaence and expenses which may in any way accrue AIR HANDUNC UMT(T010,000CFM) SUBTOTAL:
agaimt said City In<oeequencc of the granting M this permit. —
y AIRHANDLING UNIT(OVER t0,000CFM) CONSTRUCTION TAX
1-�c\\•.� 1 L q t CON RU ION TAX AID:
Slgmture olA licant/ContnctoN Date EXHAUSTHOODM/DUCT)
_ HA]ARDOUSMATERIALSDISCIOS RE _ -■
Will the applicant or future building onipant store or handle havrdom BEATING UNIT 1Q1,000 BTU) - D'I ReC21 tN
material as defined by the Cupertino Municipal Code,Chapter 9AZ and the -
IlealthandSafety Code Scalon 25532(a)7 HEATING UNIT(OVER 100,00)BTU) TOTAL: Y54G.3rj
\ ❑ Yes MN.
Will the applicant or future building occupant use equipment or devise VENTILATION FAN(SINGLE RESID) CSSC� .-E DATE
which emit hara dou.air mnta Mums as defined by the Bay Area Air .
Qct lily Management District? BOILER-COMP(3HPOR100,IXDBTM
4Ye' No FER 1419JT
haveeadtheh ,�OusmteaurcgiremnnunderChaper6.95of BO LER COMPOVIIIW,000BTU)
the Glifomu Health A Safety Code,Sections 75505,25533 and 25537.1
understand that if thc6uilding does not mrrently M1aveatenanL that it is my NEW RFSIDENTIALMECH. SQ.Fi. .t
rrsponsibility to notify the ocapant of the requirements which rust be met (J 1M"a.n
prior to issuance
Owner1,m-a'J\ofa Certificate
a�ofh Ocmpancy.
uth�erDate
'
TOTAL ISSUED BYt.�_1�
OFFICE COPY