21521 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building PruecI Identification I PiiRMITNO.
Building Add..: 21521
w r"
Phone: A A A
ate.` CITY OF CUPERTINO-BUILDING DIVISION O
�' co/npGactoraNam: Lk.No: APPLICATION / PERMIT
�-a--t/C- LIU BUfLDINGELECTRICALPLUMBINGMECHAMCAL CATEGORY COyTRBbM I
Architect/Engin r s LIc.Nqq� lJ '� l
OU rO1J �� c{�o Z C9�o Lb QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE O ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I Mh lamlicessed ivsi=3ofheunder Busi esexand Pro Chapter9de,and nc APPLIANCES-RESIDENTIAL JOB DPSCRB'i'ION
ingwit I Section 7000)ot Divislon3 olthe Buslneasand ProfesslonaCodc,and my
B lain full! and d(ect. �t PANES
Limnse Class Lk.N 4 0 SC T '"'11 ✓'
Date I 1_Contractor v57 l,,
ARCHITECTS DECLARATION 201-IODOAMPS
M z I understand my plans shall be used as public records. OVER 1000 SQ.FT.FLOOR AREA 4/SQ.Fi.
CO
Z Licensed Professional S GNS ELECTR C
Q 61 OWNER-BUILDER DECLARATION SPECIAL NT/ I
i.., 7 1hcmbyaffltm that l am exempt from the Contractor's Licanae Law for the
Q F'� following recon.(Section 7031 S,Business and Professions Ce:Any city or TEMP.METER L
p county which requires a permit to construct,slier,Improve,demolish,or repair
q a any structure price to its issuance,also requires the applicant for such permit to WERD
66 V file a signed statement that he is licensed pursuant to the pmvlalom of the
Contractor's License Law(Chapter 9(commencing with Section 7000)of)lvl- S POOL ELECTRIC VALUATION
O sion3olthe Buslnessand ProfessionsCodidorthat hale exempt the 13;:nd
the basis for the alleged exemption. Any violation of Section 715 by any glyl.rc
f3 oGX appH.et fora permit a.bjectsthcappllcanitoa civil pevlty of stat more than i
fQS five hundred delta.($500). RESIDENT[ E SQ.Fr. STORIES TYPE CONSTRUCTION
F11,as owner of the property,or my employees with wage.a their sole
ca rnpcm.fim,wUl dothr work and thestructurcb not Intended or offered for
psale(Sec.7044,Business and Professions Code:The Contractors Llomse Law
5$ docs not apply to an owner of property who builds or improve thereon,and OCC.CROUP RFS.UNITS
who doessuchwork himself orthrough hi.ownemployees,provided that such
improvements arc not Intended oroffered for,ale.If,however,thebuilding or TOTAL:
Improvementlsaoldwithinoneyearofcompldiogthe wner-WBderwlllhave
tl�rden of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with limned PERMIT ISSUANCE
contractors to conswct the project(Sec.7014,Business and Professlom Code:
The Contmcto'.License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA)
Wilda or Improves thereon, and who comeacts for such ptajects with a
gqRREE�ractor(s)licensed pursuant to the Contractor's License Law. BACK FLAW PROTECT.DEVICE FEE SUMMARY
c'
Ll I am exempt under Sec. e k P C for this reason '
I DE FEES
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
Owner ---_—Date R— N
K M
WORAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCJTOOL TAX Y N
M1 hereby affirm that 1 have a certificate of consent to self-Inwre,ora RECEIPT N
ctAiflateo(Workeri Co Nmationimumomoracertifled copythermf(Sec. GAS FA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
3800,Lab C.) RECUPT
Policy GA .SYSTEM-OVER DING
S EAN
Com any BUILDING DIVISION FEES
W-miflod copy b hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy is filed with the city Inspection division.
GREASETRAP
CERTIFICATE OF O(FMPTION FROM WORKERS' PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA.200FT. Date ccei # Ik0
(rhis section need not W completed If the permit lsfw ora hundred dollars
(SI00)or le®.) WATFRHFAMW/VENT/ELECTR ENERGYFE Y� N
1 mrtllythat N the pedormanm of thework forwhlch this permit la bwcd, 3"
I ahall not employ any person In any manner so aa to became subject to the WATERSYSTLM/TREATING
Workers Compeniatlon laws of GII(ornla. Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Re t#
Z O NOTICE TO APPLICANT.If, nuking this Certificate of Exemption,you
F N should become subject to the Workers'Compensation provisions of the Labor TO
c Code,you must forthwith comply with such provisions or this permit shall be BUIL C "E 11 CIO
deemed revoked. SEISMIC FEE 1_
LU _ CONSTRUCTION LENDING AGENCY
CL ° Ihereby affirm that there his construction lendingagency forthe performELECTRIC FEL
n ance of the work for which this permit b bsued(See 3097,CIv.C) TOTAL:
U O [enders Name PLUMBING FEE
LL F Lenders Addres, QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Icertifythatlhavereadthlsapplicationand sawthattheabovelntorenation
O W bsmrrect.l agree to comply with all city and countyordlnances and state laws PERMIT ISSUANCE FEES PAID:
r 1 relating to building construction,and hembyauthorlre representatives ofthis
H Z cityto enterupon the abovcmentloned property for Inspection purposes. ALTIXORADDTOMECH. Date Receipt#
k,a�'Ic
e)agree ve,Indemnify and keep harmiess the City of Cupertino AIR HANDLING UNIT(TO t0,OD0 CFM)
VtlW c,' dgeems,costsand expenses which may In anywayamme SUBTOTAL:
Ida mxan.ap,enm nen ml.PennaCONSTRUCTION TAX
AIRITANDUNcuNTr roVERIB,BBocFM)L— a CONSTRUCTION TAX PAID:
lure ofA nt/Contrctor Date IXHAUST HOOD(W/DI1CT)H RDOUSMATERIALS DISCLOSURE
IIIcppBca� or future building occupant store or handle hazardous I'[EATING UNIT(TO 100,000 BTU) Date Reeei t#ial sdafinF by the Cupertino Municipal Code,Chapter 9.12,and the
Iimhh and Safety C1<.N-
25532(a)7 HEATING UNIT(OVFR 100,000 BTU) TOTAL: 0 aI
F-1 No
Will the applman um building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUAVl;IgZE.
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management Di -COMP 0HPOR IOO,0W BTU)
ct2 BOILERYea No_ DEC 1 91�U
I ave read the ha Wins materials requirements under Chapter 6.95 of BOILER-COMP(OVM100,000 BTU)
the California Hrahh h Safety Code,Stolons 25505,25533 and 25534.1
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQI7. City.aa....��NNys..� ..y{��
rapmaibil notify the ompant of the requirements which must be teat of C1pAYno
prior to a ce oto Certificate o(Occupancy. E�j�
nee ora thorired DateISSUED BY
TOTAL:
OFFICE COPY