21881 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO,
Building Address: 21881
1881
7 28 ( eL
wn aero: one:
CITY OF CUPERTINO-BUILDING DIVISION J'
Contraar'a Name: u5." : APPLICATION / PERMIT I
a`^ L HMLOING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL 0
Ylrc rect/Engineer. Llc.Nm
"• BUILDING PERMIT INFO
QTY ELECTRICPERMIT FEE
Address: POWTISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby usimmaonsof Chapter
ssion,9(mmmm API'I.IANCESR}SIDENML - JOB DFSCRU''FION
license I Sod1on7000)of d vlelon3oflhegusineesand ProfeseioneCade,and my
License Is In cup tore¢ d erred. 6 I _-_ —I PANELS i
License Cha ilea L• Q L"
Date;-
ARCHITBCI•S DECLARAT- IORI' O VE
AMP"'
{qq{++++9 ZO I understand my pians@hall be used u public records OVER 1000 AMT'S 5Q.FC.FLOOR AREA f/
h Ltmnsed I'mfealmul SIGNSELECTRICAL
I<6 OWNER-BUILDER DECLARATION
n01
71, Thereby ef0rm tbetlam exempt incentive Contractor's License Law for the SPECIALCIRCUT/MISC
qqqqqq following reason.(Section 70715,Rusin and Professions Cade:My city or
f" countywhlcheequlrn a permit tocanstmct,alter,improve,demolish,orcepair TEMP.METER OR POLE INST.
4q'O Q aey.trudurc prlortoltsle amu alsorequimstheappBcantforsuchpermltto POWER DEVICES
0�U B4 a signed atstemCnt that he Is licensed pursuant to the provisions of the
3w� Contractor'sui esldProfaw prWmCod )orthathebmmpthamfmfDivi- SWIMMING POOL ELECTRIC VALUATION
H OS dan3o(tfie BucInse adPro(embnsCoer 9 mmening with
esemon7000fmm and
t<,
the bub for the alleged exemption. Any violation of Section 70715 by any OIJILETSSWITCHESF!%IURES
applicant fora permit subjects the applicant to a civil penalty or not mra othan r 0 O
fiveundred dollars(5500). NEW RESIDENTIAL ELDCTR SQ.FT STORILS TYPE CONSTRUCTION
�n I,an owner of the property,or my employees with wages a their sole
C compematlon,will do the work,and the structure is not Intended or offered for
S O ale bee 7644,Busboss and Profemlow Code:The Contractors License Law
pR2 does not apply to an owner of property who builds or improves thereon and C.GROUP RFS UNITS
6 who doeaeuchwork himself or through hisown employees,provided that such
improvements are not intended oroffered forsale.If,however,thebuilding or TOTAL:
Improvement Issold withinoneyearofcompletion,the owner-builderwill have
Itr*rden of proving that he did not build or improve for purpose of eale.). Cry. PLUMBING PERMIT Org
u L as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
contractors to construct the project(Sm 7044,Business and Profeaslons Cade: PERMIT ISSUANCE
TheContractor's License Law does not apply to an owner of property who ALTER-DRAIN&'VENT-WATER(EN
builds or Improves thereon, and who contracts for such p(oject,with a FEE SUMMARY
�N(adse
or(s)Rcend pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
LJ 4 am exempt under Sec. B&P C far this rattan -
• �\ Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY RECEIPTN
WORKMAN COMPENSATION DECLARATION FS
01 hereby affirm that I have•certificate of consent self-insure,o a EIX'lURPER TRAP SCHOOLTAX Y N
AECEB
cediflteo(Workers CompematlonlnsuranmoramnifiWmpythereaf(Sec. CAS EA.SYSTEM-11NC.90IJILEfS PARK FEE N
♦__ 3ROO,LAb C.) Y RECEIPTPaltry f ca"! EA.SYSTEM-OVER 4(EA)
Com any BUILDING DIVISION FF.[S
Certified copy is hereby furnished. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy b riled withh the
e cicity inspection division.
CERTIFICATE OF EKEM PTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 20DFT Dale Recei t#
(chis section need hot be completed if the permit isforone hundred dollars
(fI W)ar lean WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I ermlythat in the performance orlhe work forwhIch this permit I.Issued,
I shall not employ any person In any manner so u to become subject to the WATER SYS.TFM/TREATING
Workers Compensation laws of Cellfornb. Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date RCxI t#
Z O N077CETO APPLICANT:If,after making this Certificate of Exemption,
should be..sub)edtothe WmIccro'CompersaUan provisions ofthe Labor � � TOTAL:
ir N Code,you must forthwith comply with such provisions or(hb PemNbhallbe B ��
W > deemed revoked,
f] CONSTRUCTION LENDING AGENCY SEISMIC FEE
d IhembyafBmnlhattheerbacc fraction lending agency for the perforin TOTAL: ELECTRIC FEE
7 Z ance ofthe workfor which thin perMt is Issued(Sec.3097,Civ.C.)
LL 0
iLender's mea.. QTY MECHANICAL PERMIT FEE PLUMBING PEE
LL MECHANICAL FEE
OW I certifythatl have resdthisapplicalionanci statethm lh..We.information
S is correct.I agree to comply with all city and county ordinances and Yate laws PERMITLSSUANCE FEES PAID:
Y W relating to building construction,and hereby authorize mpremntativa ofthis
city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
Z
Z (We)agree to ave,Indemnify an d keep harmless the City of Cu petitionDa[C RCCCI t#
ago st Babllltles,judgments,mrte and expenses which may In aywayamue AIR HANDLING[INTI8010,000 CFM) t SUBTOTAL:
a t said City ro .e..of the granting of this permit.
—` _ AIR HANDLING UNIT(OVER IRODOCFM) CONSTRUCTION TAX
7� Stlytiture of Applicant/Contractor Date EXHAUSTHOOD M/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MAT. IALS DISCLOSURE
Wlilthe applicant or future building occupant store orhandle hazardous HEATING UNIT(TO!00,000 BTIA Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 Z,and the
Health and Safety Cad,ea-Section 2S532(a)7 HEA (0 B
TING UNIT(OVER 100,0TI!) TOTAL:
E
Ya No
illrhe a pplleant or rum building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
I which emit hazardausair contaminants as de0ned by the Bay Area All ���
Quality Management District? BOILER-COMP(7FR'OR 100,000 BTU)
❑Yee 1.No
Ihave read rhe hazardous materials requirements under Chapter 6.95 of BOILER-COMP(OVER100,OOD BTU) A �QAl
the
California Health&Safety Code,Sections 25505,25533 and 25539.1 41AR 1 �7s�f• [ r
"understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. S cAr
mpomlbWly to notify the occupant of the requlrcerenb which must be met
Prior to lsuance of.Certificate of Occupancy.
Ownerm..thadced a gent Data ISSUEDBY_4, r-
TOTAL:
OFFICE COPY