21720 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project ldrmilkatisn �oY V ` PERMIT NO.
Building Address: 21720
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Ur.RAdd�..
one: A A A IL
CITY OF CUPERTINO-BUILDINGDIVISION ' _ Z C1 1
iNa� / L )�y-9• APPLICATION / PERMIT
® �' Cr t-a BUILDING-ELECTRICALPLUMBING- CATEGORY CONTROL#
glneer. MECIIAMCAC
12Z2n n� TY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
PFJtMITI4UANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby all that l am licensed under provisions of Chapler9(comment, APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwtth Section 7000 fDivlslon3ofth/e�0ussiinnessaannjd�Pm/nNon.Cod,and my �+ 11
Date licemo lCiaa I. B( ndL�CN `4 JLJV PANELS ` 4A
Date Contractor 111L1\l rli
ARCHITECTS DECLARATION 701-i000AMP5
0! understand my plamshall be used vpubilcrtro da OVERt WO AMS �.F.FLOOR AREA ) f/SQ.F.
O
x�J Fj Licensed Prafesshmid SICNSELFCMCAL .�/s /�/'�
G OWNER-BUILDER DECLARATION SPECIALCBtCUT/MiSC r`••'
I_ , Iherebyaffirenthat lamexempt from the Comead.r.Lt...e law fee the
Q fo 1owin re.,i ectlon 7M 1.5,Business and Professions Code:Any city or 2
rr j,lil county which mqulresa permit
uame,a o mquies the aprov,demolbh,or repair
-q � any structure statement
tor to ements Lat he Is Ib osed pursuant to the prouch visions
ofpermit e ]CWER DEVICES
EE ry S file a abed LLatemeLa that he b II¢nsee pursuant it the pon 7000) of the
i.
i-
Contractors ft a use .d PCh .r mC mmencing thathe h Sectimmpt hem)of and SW Md NG POOL ELECTRIC
Q he of the Buaincsa and PrdcssbmCodel orthat hebexem therefromand VALUATION
5 the bust.for the alleged exemption. Any Wolatlon of Sectloe 70015 by anyO } 0100
� is
applicant for a perMt.objects the applicant to a civil penalty of nn more thanFrru= U
o� five hundred dollars($5M.
as owner of the property,oremployees with wa es as their sole R 0 L STOW s TYPECONSTRUCI'ION
-11, P PertY. mY6
�Z¢ compcnsatlon,willdothe work andtheawmnre boot Intended or offered for
n
sale LSec.7064 Basin..and Pmmadms Code:The C.etranor'a License law
�S$ docs not apply to an owner of property who builds or lmprovn therms,and
who does such work htmalf or through htsown employee,,provided that suchCCC.GROIIP RES.UMTS
improvements are not Intended proffered for sale.IL however,thebuilding or _
improvement b sold within oneyear ,ofcomplctlor,the owner-builderwlll have
tl) mien of priming that he did not bund or Improve fee purpose of sale.). QTY. PLUMBING PERMIT FEE
L L as owner of the a FLOOD ZONE APN
property, 70K exclusively EM a mngwithetCode- PERMIT ISSUANCE
TheconContractors
act comwn the w doe(Sec.apply
Business and of Prop rt Cade:
The Coor Improves
es the Lw don net apply to an owner d property who
Wilds or Improves thereoq and who contracts for such PPkrn with a ALTER-DRAIN At VENT'-WATER(EA)
<oL_jI or(.exempt under Sotto Me Contractors License Cfo BAQC FLOW PROTECT.DEVICE FEE SUMMARY
LII am exempt under Sec B k P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
• — OUTSIDE FEES
Owner Date ' RECmTs
WORKMAN COMPENSATION DECORATION FIXTURES.PER TRAP SCHOOL TAX Y_ N_
❑I hereby affirm that I have o certinc nc of consent to pytheure,ee a REC IIT N
cenlflLab of Worken'Compemtllonlmurance eea certified ropy themo((Sec. GAS F.A.SYSTEM-1 INC-4 OUTLETS PARK FEE Y N
3500,lab CJ
Policy IF GAS EA.SYSTEM-OVER A) DINGDIIIPT e
Com any tlU1LUINC DI VISION Fr.ES
ECertifled copy is hereby furnished.
cid. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCI JECK FEE
�CertJied ropy b(fled withh the city Inspection division. PLAN
CI
OF E(EMITION FROM WORK ERS' GREASE TRAP PAID
alm)orlca3
COMPENSATION
O NSATION INSURANCE
(Thbunlon need.oil b completed bfor one hundmd dollars
SEWER-SANITARY-STORMEA.30OFT. Date Recti t# `
]certify that In the perfomunceof the work for which this permit bIssued, WATER HEATERW/VENT/ELECTR ENERGY FEE Y N—
I shall not employ any person In any manner n n to become subjen to the WATER SYSTEM/TREATING
Worken'Compensatlonlaws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PIMB. SQ.FT. Date Reuel t#
Z O NOlicant APPLICANT:If,ager making this Ccrtlfkate of Exemption,you
should become mbject to the Warken'Compematlon pmvidj of the Labor TOTAL:
W~ W Cade,you most forthwith comply with such provbiom orthb permit shall br BUILDING FEE
y dimmed revoked.
CONSTRUCTION LEADING AGENCY SEISMIC FEE
a O IhrrebyafflrmFiat there b a construction lemIteg agency for the perform TOTAL: ELECTRIC FEE a
Z anceafthe workfor which this permit is based sec.3097,Civ.C.)
(� O lenders Name 1-7 !. PLUMBING FEE
LL ~ Iendrr;Addrea.7�/lr QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icerti(ythaH love readthbappliu onand tlatethal theabove tnformadon
bcmlalln,to geed,complywlthalldhemb autho rdinpn nn dstate law. PERMIT ISSUANCE FEC ��
N cityt.elue'ulidln t comtrunlon,and hereby property
mprexnPulp ofthis J
H Z cityW) give
I. ave,indemnify an d propertyfor the Cit purpose. ALTEROR ADD TO MECH. Date Recei tilt
— (We)agree to save,indemnify an d keep harmless the City of Cupertino P
against liabilities,judgcoeand expenses which may In mtt
ywayarue AIR HANDLING UNIT CTO 10,"CFM) SUBTOTAL:
isect ets
agahut said Cna fthe dthb emit.
�(V•// AIR HANDWNG UNR(OVER IO,000 CIM) CONSTRUCTION TAX
4 CONT UCTION TAX PAID:
Sigmtum of Ap nil/Contractor / Date IXIUUST HOOD(W/DUCT]
ILRDOUS MATER] SDISCLOSURE - I qj_ bnySI;
Will the applicant or future building o pant store or handle hazardous HEATING UNIT(TO 100,000 BN) —i Date RCCei tit
material as defined by the Cupertino Municipal Cod,Chapter 9.1 7,and the
I lcalth.mi Safety Code Setion25532(a)? HEATING UNIT(OVER 100,000 BTU TOTAL: L
F-1 ye, M No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which enter hxvndom air cont.Mconts as defined by the Bay Area Air
lily Management Citrin? BOILER-COMP OHP OR IMM BTU �,��1r
I�+� Yes I.No f pin
Ibavereadthe havr�Ous materials rcqulmments underChapter 6.95 of BOILER-COMP(OVER100,000 BN)
the Ca lifomla l lealth h Safety Code,Sen Ions 25505,25533 and 25536.1 FEB 141991
understand that lithe building don not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT
rmpomibilityto naify the«sopa.of the requlrtments which must be met t
prior tom cc o ate of pan
Owner or autho' dagent Date TOTAL: ISSUED BY:_
OFFICE COPY