21855 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERWT NO.
Building Address: 21855
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came: one:
�' 06Le e 72 ^+ CITY OF CUPERTINO-BUILDING DIVISION
• G°"m'°°r'e Lie.No: APPLICATION I PERMIT,
BUILDING-ELECIWCAL-PLUMBING-MECHANICAL CATEGORY CONTROL N -
Archlten/Fagineer. Lk.No:
.Qry ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Adtlreu - 1'FRhITISSUANCE El El ❑
LICENSED CONTRACTOR'S DECURATION
Chapt
Thereby eon70thadapt BcensM under re Chapter9de,and APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwhh Sectfon 7000)onDiv feet. lthe Businem and ProfemlonsCode,and my
license Isinfull force and c. PANELS nI
License Clam Cont 1
Dale GOntia ROr —UP TO 200 AM5
ARCHITECTS DECLARATION 201-IOW AMTS
0 0 I
understand my plans shall be used as public records. OVER 1000 AMPS SQ.FL FLO A $/SQ.Fr.
CO
b(/ Licensed Professional SIGNSELECTRICAL
6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
1herchyaffirentbat I amexemptfromthe Contractor'sLicense,Lawfor the
rotealons Code:Any city or
F many which requires a permit to construct,alter,Improve,demoltsh,oreepalr TEMP METER OR POLE 1NSf.
5 .+ a nystm=mpriortoirei mance,aLsomquimatheappliantforsuchpermltto
r file a signed statement that he is licensed pursuant to the provisions of the
fallowing reason.(Section 7031.5,Business and PPOWER DEVICES
�Ow Contractor'sLlcerue Lw(Cl pter9(mmmm�dngwithSecHon70m)ofDIA-
•O SWIMMING POOL ELECTRIC
the bass for
the aIle a dexemptions Any violationthat is exempt therefrom and VALUATION
6 Of
the basis far the alleged exemption. Any violation of Section 7(p1.5 re any OUTLETS-SWITCHES
1vcapplicanthundred
fees permit subjectethe applicant to a civil penalty of no[nnrethan
00 flue M1un s ownerlanhe W).
NEW RFS[DFN7IALELECTR PT.
�n I,as ownerofthe property, i my employees with wages as their sole �' STORIES TYPE CONSTRUCTION
compensation,Sustained,
workandthestructurebna Intended orofferedfor
D suis(Sre 7074,Buslnem and Pro(emlom Code:The Cantactore License Law
$ does not apply to an owner of property who builds or lmprovm thereon and .GROUP RES.IIMTS
EE whodoeaeuchwork himselforthraugh hfsownemployees,provided that such
improvements are nor Intended oroffered torsade.ILhowever,lhebuildingar TOTALN /
Improvement ismld wfthinoneyearofcomplelion,the ownenbullderwill have
t))rkureien of proving that he did not bund or Improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE
L J FLOOD ZANE " APN
I,as owner of the property,roject em exclusively c.sod
with licensed PERMIT ISSUANCEcon
The,ractors Comma rowWct the project(Be.apply to an o ane of f.kinsproperty
Cade: '
The Contractor's Llama Lw docs not apply to an owner a property a ALTER-DRAIN Is VENT-WATER(EA)
builds or improvesthereon, and who contracts !a such p(oJem withth a FEE SUMMARY
1R�Taamexempt under ant Sm
the ContraaloreLlansc Law. BACK PLOW PROTECT.DEVICE - �rpD
/may am exempt under Sea R 4 P C for this reason
A ' / DRAINS-FLOOR ROOF,AREA,COND. SANITARY Y N
neo Date
RECEIPT p
WOR m t CO have
.ce ION f cense A ON FIXTUIRFS PER TRAP SCHOOL TAX Y 'N
certifi❑f hereby affirm that I have o artersecifieste of concent to copy
thereof
ora RECEIPT M
MM,abte o(Warken'Comperwuanimuanaoraartifled mpythereof(Sec. GAS FA.SYSEM.1 INC.4 OUTLETS PARKFEE Y N
38 W,Lb C.) _
Paltry p GAS.EA.SYSTEM-OVER 4(EA) IRECEI'T p
Cany BUILDING DIVISION FEES
amFCertified copy as hereby famished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
F1 Certified copy Is filed with theecity city Inspection division.
CERTIFICATE OF IXEMPTION FROM WORKERS' GREASETRAP PAID
a
COMPENSATIONINSURANCE SEWER-SANITARY-STORM EA,2MFT. Date RCCeI t#
(Thiactlon need na be completed If the perMt 6lor one hundred dollars
(51 W)orfept) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Iartlly that in the performance W
ofthe work forwhlch this permit is ted,
I shall not employ any person in any manner w as to become sullied to the WATER SYSTEM/TREATING
Z
Workers'Compenmtion Laws of California, Date PAID
Z Applicant
Z O
NOTICE TOAPPLICANT.IL after rs Co this Certificate ofonExemption,Labor NEW RESIDENTIAL PLMB. SQFT. Date RC i t#
H Code,shoulyou brourne
forth it the Workers'such provisions
orthdovrmit s Lab or TOTAL:
lY N Corrscde v ked.forthwith comply with such provbiav orthle permit shall hm BUILDING> deemed revoked.
W
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
fhembyafflrmthat there is a construction lending agency for the perform- -Ga jl ELECTRIC FEE
M Z anofthe workfor which this permit It Issued(Sec.3097,Civ.C.) TOTAL;
a VV
02 Lenders Name PLUMBING FEE D O
IL F- Lenders Addrem QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W lecrilythstltwve readthisappliallonandstatethattheabovelnformation
correct.I agreetocomplywith all dtyand rountyonflnancesand state laws PERMIT ISSUANCE FEES PAID:
r O- relating to building construction,and hereby authorize representatives of this '
?N city to enter upon the above,mentioned property for impection purposes. ALTERORAODTOMFCH.
(We)agree to love,Ind emelly an If keep harmless;the City of Cu pert Ino Date Receipt#
L) agai bilitles,judgments,carts and expert.which may In any way accrue MR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
a namid Cityla mnqueraofthe it ethld permit. G
ftf /I AIR HAb3DLING UNIT(OVER I0,W0CPM7 CONSTRUCTION TAX
Sigmmreof Applicant/Contractor Date EYHAUSTHOOD(W/DUCT) CONSTRUCTIONTAX PAID:
HA2AR DODS MATERIALS DISCLOSURE
Will the appllca nt orfuture building ocm pant at.,Ctch
haand le hazardous HEATING UNIT(TO 100,W0 BTU) -Date RCcel t#
matetlal as dell tied by the Cupertino Municipal Code,Chapter 9.17,and the -
Health and Safety Code Section 25532(a)? HEATING UMT(OVER 100,000 BTU) TOTAL:
E-1YenNo
Will the applicant or utum building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) IS ATE
which emit hazardous air comered.nb as defined by the Bay Area Alr
• Qu a lily Management District? BOILER-COMP OHP OR 100,000 BTU) 919('1
4 Yes rd No
have readtheb. oue materials requirementsunderChapteril.95 of BOrLER-COMP(OVER 100,000 BTU)
the Califemia I Icalth k Safely Code,Sectlom 25505,25S33 and 25534. 1 ,
and creta nd that if the bu llding does not currently have a tenant,that it Ex my NEW RESIDENTIAL MECH. SQ.FT. p14y wi Masans�j�
rmpmrslbility to notify the occupant of the mqulrements which must he met City Yd VVUUII''w--
prior to issuance of a Certificate of Occupancy.
Owner or authorizedagord Date ISSUEDB V[�
TOTAL:
OFFICE COPY