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21049 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY building Profs Identification PERMITNO, Building Address: BLrr�1 D I O 21049 W mr� ama: 011e: I oVl 1T:4- CITY OF CUPERTINO-BUILDINGDIVISIONq 2 � ° tractor'.Name: Lm•No: APPLICATION I PERMIT I �J kcl FiG ILO S�-ZICATEGORY CONTROL# Ar7rih1itlen/Engineer, -..�:�..aal1���� Ie No: BUILDINGET.ECTRICALPLUMBINGMEGHAMCAL uLa&*-S QTY ELECTRIC PERMIT FEE �rBUILDING PERMIT INFO Address, G PERMIT ISSUANCE IZ� ___R= UbLi PLUMB MirFr- 4,y K ® K LIC Rcm C err Woos TION ,y y'' �J Ihth Sbftl70th)fDivim3ofheSusiwWomofCssions9de,and -` APPLIANCES-RESIDENTIAL R,(no JOB DESCRIPTION Ingwlth Section 7000°!Dlvffeet. ofthe Bueloeaaand Pro(eanionaCode,and my licenm is In(u to Rntra Zi PANELS / ,tea License Clam LieaT K jjll �I Date Contactor a1 ARCHITECT'S OE A ON 20]- AMT'S Oa Zp Iundentaad mypi ..hall be used as public records. OV 1(100 AMT'S SQ.Ff.FLOOR AREA S/SQ.FT. �6� Licensed Professional I 9 ELECTRICAL `O ^ OWNER-BUILDER DECLARATION �f &LALCIRCUIT/MISGf" Z. .4 I hereby affirm that l am exempt from the Contractor.License Taw for tha. 0 pp following reason.(Section 7071.5,Bualness and Prof anions CSde:Any city ar 'E •R P O ZTEMP.MEI'FR OR POLE INST. p carntywhkh require))pj;c Snstroct,alter imp e,drmolbli,arrepalr J , anystacarepnorto its lslso requlre.2feapp lantforsuch permit to Y r1'03VERfile a signed indenter,thlrinxd pursuant tothepeavialoluofrthe,O wI. Contractor.License lawr9(commencing with Section)000 of DM- BOJon3oftheBuslnemendOns Code)orthat hebeumptthere(•rjlt fid SWAIMINC CCTR[C VALUATION Sn....7777 the basis for the alleged exemption,, Any violation of Sectio 703 by any a B Q applicant fora permitaubjecte theapplicant to a civil penalty ..tabs. OU7LEISSWI7C FIXTURES $ five hundred dollars($500). ";1, C �n I,as owner of the property, my P y %'" RES PMIAL ELEGTR_SQ}7, STORIES TYPECONSIRUCTION ❑ p party,or em 10 eo with wa as their sole 5 compensation,will dothe work,and lAestrunure isnot intend oroffcicit(ore 5 O sale(Sec.7049,Bualneu and]P��rofftunkms Code:The Contract e.Uoejrs>ar�LXW. �$$ does nal applyto an owner oTpmpertywhobuild'arlmp nthereogland:, OCC.-GROUP RES,UNITS whodoe such work himself or through hisown emp11. s rovlCed that such improvements are not intended oroffered forwk!If,how cgtheliulldinga TOTAL: " L improvement bsoldwllhinoneyearofco ptetlogthe r-bu0derwlllhave theburden°lprovingthal hedidnMbuildcrlmproveI purposeofmk.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN M L as owner of the property,am exclusively mntr ng with licensed PFRMITISSUANCE contractors to construct the prefect(Sea 7074,Business and Profe aloru Code: The Contractor's License law does net apply to an owner of property who ALTER-DRAIN&VENT LINTER(Eek) Wild, or Improve.thereon,and who contaaM1 for ouch p(ojacta with a �q0.t ceor(s)Banned pursuant to the Contractor's License Law. BACK FLOW PROTECT'DEVICE FEE SUMMARY LJI am exempt under Sec. B k P C for this reasonOUTSIDE IF Owner DRAINS FLOOR ROOF,AREA,CON I. SANITARY Y N . Date WORKMAN COMPENSATION DECLARATION RECEIPT N pp(TURE&PER TRAP SCTi00L TAX Y N {iI heaby)(firm that 1 have o certificate of consent to opy tnwa,or RECER'T I, 3800 als afWarke�ln',C,amperwticonlnsuanaora certified ropythertroflSec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N l ry bC.) I -0 ZJ I�J Poll Y DING DIM Com an GAS FA.SYSTEN-OVER4(EA) y� ^� BUILDING DIVISION FEES �Certlfiedco ere mbhed. 1�-wF' _.Py-s GREASE WASTE INTERCEPTOR TEA NCHGCK FEE Certified copy is filed with the city lepred dlvi.loA n. CERTIFICATE OF FIXEMFT[ON FROM WORKERS' GRFASR TRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.20OFT. Date Remi t# (Thlnnection need not be complcted tithe permit V(Drone hundred dollars ($1I unify that WATER HEATER W/VENT/ELHCTR ENERGY FEE Y N Ill not thato the Nnsouiaofthenner an as t bthispermit1.trued, — I.hall not employ an/person In any runner n m to become eubjecl to the WATER SYSTEM/TREATING Workers Compenutlon G...(Gllfomla.Data PAID O Z NOTICE° Date Rerei t# ZO NOTICEco APPLICANT:If, arkem-fter komNasation pmvuiomofthen,you NLIV RESIDENTIAL PLMB, SQ.FT. C de yoecomeeubjecimthe p°yk s'Compenaation Tmvbimuofthetabor TOTAL: LU N Cede,dmv krttorthwlth comply with each proWalons arta.peaNt shall6e Z 7 deemed revoked. BUILDING FEE by LU GCONSTRUCTION LENDING AGENCY SEISMIC FEE Ihereby affirm that there is a construction iendingagency for the perform Z ELECTRIC FEE s Q ance of the work forwhich this permll b issued(Sec 309-/,Clv.CJ TOTAL: �a 1 V O Iander's Name PLUMBING FEE LL H ender'.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE O W I certitythatl have read lhasappllcationand state thattheabove information ,,aa.s��'� ucome.l agree to comply withal)cityand countyordlnancnaand sate laws PERMITISSUANCE IZW FEES PAID: >. relatinglobuilding construction,and hereby authorize representatives ofthla F N ty to enter upon the above,mentioned property for Impection purpose. ALTERORADDTOMECH. Z (We)agree to give,Indemnify and keep harmless the City of Cupertino Date Receipt# V a gainrtliabillliliuud mens,codaandexpeme.whichmayloanywayamme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: againsteld City ro ance of flee. I Ing of lhls permit. J' �kl� J��� AIR HANDLING II[uTI'(OVER IO,OOgCFM) CONSTRUCTION TAX �4 641A.,..{/ ''' CONSTRUCTION TAX PAID: 5 nature of cantARDO ctq Date EXHAUST HOOD(W/DUCT) (�' HA7ARtureb TRIALS DISCLOSURE Willtheapplics redrat byreurebuildingomipalCode, hhand1.M1avadthe I-IFATINGUMT(TC31W,000 BTU) Date Recei t# ureteral as dented by the Cupertino Municipal Code,Chapter 9.17,and the - F Iealih and Safety Code Section 25537())7 }[EATING UNIT(OVER 100,0W BTU) TOTAL: 1 ❑ Yea �h Will the applicant or mrc building occupant use equipment or d.vices VENTILATION PAN(SINGLE RESID) AUJMFE DATE which emit hazardous air contaminants as defined by the Bay Area Air 1�' . Quality Management District? BORER-COMP OM'OR 100,00 BTU) I-1 Yes rF ave read the baza o..materials requlrements under Chapter 6.95 of BOILER-COMP(OVERT 00,000 BTU) jE 1 O s7+7 the California Health k Safely Code,Sections 75505,75533 and 25534. I understand that if the building does not currently have a tenant,that it is my NEW RES[DENTTAL MECH. SQ.FT. ,,L empoodillity to notify the occupant of the requirements which must be ret Aifs/ (�f ri1QB'II.rA prior to lanuanceo rt atoofOrou ancy. Go - Owner or aulhorized gent Dale TOTAL: 10 ISSUED BY: lJ VY1'V1W Vv'�"""N. OFFICE COPY