21627 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 21627
SGrn Lk
I roane:
A
..� CITY OF CUPERTINO-BUILDING DIVISION
c°cra Lic.No: APPLICATION /PERMIT
o �—
3`y e va- Ad P- rna n BUILDINGIZFCTMCALPLUMBING-MECHAMCAL CATEGORY CONTROL#
Architect/Engineer. Lie.No:
QTY ELECTRICPERMIT' -FEE BUILDING PERMIT INFO
-
Addrcse: PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provlslnnsof Chapter 9(comment. APPLIANCES-RESIDENTIAL JOB DFSCRUFTION
ingwlth Sedlon7000)of Dlvhloo3 ofthe BusheagandpreficenonsCcdc,and my
license is In fail to.and d(eitt PANELS /
Llanse Chea Licit /l/ �c, % /
Data Contractor l u L e� 111
ARCHITECTS DECLARATION 201-1000 AMPS
0Z I understand my phre shall be used as public recrrdw OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
CO
(0 Licensed Prdesaiwul SIGNS ELECTRICAL H A L E D
Flaa OWNEWBUILDER DECLARATION SPECIAL CIRCUIT/MISC
I hercbyafRrm that lam exempt from the C etracor'e License law for the E
po following reason.(Section 7031.5,Business and Professions Code:Any city or -CI {� �I
F2 � countywhic mqul apermlttommtmd,alter,Improve,demitsh,orrepir TEMP.MFTIR ORPOLE]NBT. M P T
.Qa anyauunumpdortaltshmancgalddrequlrestheappllantforwchper tto POWER DEVICES �Of 30/9
V file a signed statement that he Is licensed pursuant to the provisions of the WE
3p� Cmd.dord License Law(Chapter 9(mmmentlng with Section 7000)of Clot. SWBr[hONG POOL ELECTRIC
L, sion3ofthe Businessand Profealoru Code)orthathebemmptthemfmmand VALUATION
the bash for the alleged exemption. Any violation of Section 7BIS by any
G5
applicant fora permit subjects the applicant toacivilpenalty ofndmoretban OUTLETSBWITCHESFIXTURES
Fd q five 1,as
dollars the500). NEW RESIDENTIAL ELECTR SQ.Fr. STORIES TYPE CONSTRUCTION
Q�^ ❑Las owner of the property,or he employee with wages as there dole
G rom(Sec,7lon,will do the Business
kand theatrudumhnot intended
ct.e or offeredLaw
�O sets(Sec,7614,Basions and Pro(wlon Code:The Comrado(e Llmrue Law
$$ does not apply to an owner of property who builds or Improve thereon,and OCC.GROUP RFS.UNITS
who does such work himself or through hid own employees,provided that such
Improvements arc not Intended proffered for sale.If,however,thebuliding or TOTAL:
Improvement hsold withnoneyearofcompldlomtheowner-buBderwlll have
tbae�uuNtoo f proving that he did not build or Improve for purpose ofule.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
c�[� d44,I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
ntraoce to mmtmd the project(SM 70Business and Professions Code:
•The Contractor's License Law time not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)builds or Improves thereon, and who contracts for dud pcokds with a
m-6r-en-1s)licensed pursuant to the Contradoe.Lt...Law. FEE SUMMARY
0I am exempt under Sec. B&P C for this mason BACK FLOW PROTECT.DEVICE
Owner — DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N -
Date RECEBT#
OF WOqQlAN COMPENSATION DECLARATI N pp(Tq)RpS.PER•].RAI' SC1gODL TAX Y N
Of hereby affirm that I have a certl6ate of consent to dei(-Inwrc,ora RFLEIPT#
redlflan fWmkcm Cmcpc ti.n learmaacearaartlfled copythemof(Sec'
3800,Lab C.) GAS EA.SYSTEM-t INC.40I17LEr5 PARK FTE Y N
Policy N GAS PA.SYSTEM-OVER 4(PA) RECEI T#
Cor^ Y BUILDING DIVISION ITES
Certified copy b heed with the
city GREASE/INDU5ML WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy h filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP - PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2BOFT. Date Remi t#
fl'hhuctlmn need not mbebe comcompleted if the permit h fw one hundred dollars
($10),xitWATER HEATER W/VENT/FLECTR ENERGY FEE Y N
Iunify
that in the performance of the work(orwhlch this permit Is Issued, —
I shall not employ any person in any manner so as to bemire subject to the WATER SYSTEM/TREATIN'O
Worken'Compensalion Lawdof Callfomh
O Z Applicant NEW RESIDENTIAL PLMB. SQIT. Date Recef t#
PAID
Z 0 NOTICE TO APPLICANT.If,after making this Certificate of Emnrptlan,you
Fshould become subject to the Workeris Compeeatlon provisions of the Labor TOTAL:
N Code,you must forthwith comply wlthsuch provisions orthh pernit shall lee
deemed revoked. —,BUILDING W O CONSTRUCTION LENDING AGENCY SEISMIC FEE
CLF3Iberebyaf(irmtMtthmisamm=dlonlendingagencyforthepedort TOTAL: ELECTRIC FEE ..QD
arm of the work(or which this permit h issued(Sec.3097,Civ.C.)
U O Lender's Nam PLUMBING FEE
LL F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iwdlfythatl have read thhappllutimnand statethattheabove Information
1 hcormd.l agree to comply with all dtyand county ordinances and state laws PERMITISSUANCE FEES PAID:
relating to building conetrudlon,and hereby authorise representatives of this
H city to enter upon the abovcmentkmcd property for Inspection pu rposea. ALTERORADDTOMECH.
Z '(We)agree in save,Indemnify an d kerp harmless the City of Cu perHno Date RecCI f#
against llablllBn,judgments,costs a nd expenses which may in any way accrue AIR HANDLING UNIT(TO 10,"CFM) SUBTOTAL:
br- UP
pW7.t Clty Inconecryence of the granting of this permit.
Jv / a-9/ AIR HANDLING UNIT(OVER 1OMOCIM) CONSTRUCTION TAX
pplianl/Contactor Data Ext lAus r HOOD(W/DUCT) CONSTRUCTION TAX PA ID:
HAZARDOUS MATERIALS DISCLOSURE
Will theappllcant or future building occupant store or handle haaardous HEATING UNIT(TO 100,000 BN) Date RCCCI I#
material as defined by the Cuperlleu Municipal Code,Chapter 911 and the
Healthand Safety Code SecHon25532W? HEATING UNIT(OVER 100,000 BTU) TOTAL' •�
❑ Ye �]No
Will the applicant orfuture building occupant use equipment ordevlcas VFaNTILATIONEAN(SINGLERESID) ISL G DATE
which emit hazardous air contaminants as defined bythe Bay Arca Air —
Quality Management District? BOILER-COMP OHPOR 100,000 BTU)
4 Yes No ��
have read theFaze pact matcrlah rcqulrcmcnh under Chapter 6.956( BOILER-COMP(OVER 100,000 BTU) �11
the Califernlu Health&Safety Code,Sections 25505,25533 and 25534.1
understand that lithe building does not currently have a tenant,that it h my NEW RESIDENTIAL MECH, SQ.FT.
responsibility to notify the occupant of the requirements which most be over
prior to Issuance of a Certificate of Ocmpa ocy.
Owner or authodudagent Date ISSUED By.. V
. _ _ TOTAL: —
OFFICE COPY