21927 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification - - PERMIT NO.
Building Address: 21927 2�J
I
weer+ : 90y' e" CITY OF CUPERTINO-BUILDING DIVISION A
' �e7��� ., �apW�axP
Cnritran Lic.N. APPLICATION / PERMIT 3
• 577,392a BUILDINC-E. MCAL-PLUMBINGMIGMMCAL
Archtten/Engl ser:.. Ue.Na CATEGORY CONTROL p
' 'it .BUILDING PERMIT'INFO
EL -` , •'
,QrY•1,, 'r ECTRIC PERMIT,, :,t ,FEE
Aaareaa:ti _ rERwrissuANCE 1203 ^
LICENSEDCONTRACT 'SDECLARATION
Ihereby affirm that l am licensed under provisions o(Chapter 9(commne APPLIANCES RESIDENML JOB DFSCRI'fION
Ingwith Section 7000).(Dlvision3ofthellusinessand ProfeashusCode,and my
license le In full to.and effect. PANELS ��-r�� •--ems ��tl�
License lana _ Llc.p `�I/yt
Date Contractor y VVO �/
ARCHITECPS DECLARATION / MI-IOW AMP$
N 2I undemtand my pbw ahaU be used as public remmis OVER IMO AMPS _ SQ.Ff.FLOOR AREA g/SQ.Ff.
00q.
x d V: Licensed Professional SIGNS ELECTRICAL -
6 OWNER-BUILDER DECLARATION $PECIALCDtCU1T/MLSC
Iherebyaffinnlhatlamexempt fromthe Contractors License Lawforthe -
oo following reason.(Section 7MIS,Business and Professions Code:Any city or
07F•19. cou TEMP.METER OR POLE INST. -
F� any tywhich requires ipermit smancomnaWalreath, apmvgdennWh,ormit to -
S any aM1uned statement
priemenrto te Issuance,also sed pursuant the (.anconch e of It a POWER DEVICES
floe a signed statement that he t licensed pursing to the pcu,7D na of the -
3p� Contnctora Llcerse[aw(Chaprer9(mmrt,encingwlth Senutissrefof and SWIMMING POOL ELECTRIC
soon 3.(the Buslnne end Pro(euloru Code)orthat he U exemptthere(romand VALUATION
Q
��g the boats for the alleged exemption. My violation of Semon 70.115 by any 'p
applicant fora permit sub' athea locant to a civil It of not more than OUILE7SSWITCHESFTXTURFS —``�
PP Pe )act PP Pena y �O O.D D
R nee hundred dolor;(uBq. _
�I,as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELEC7RSQ.ET, STORIES TYPE CONSTRUCTION
17¢ compensation,willdothe work and the structure Isnot Intended or offered for
y�❑ Is(Sec.7044,Business and Professions Code:The Contractors License law
�'j$$ does not apply to an owner of property who builds or improves thereon,and OCC.CROUP RES.UNITS
y 0. whodaea such work himself or through his own employees,provided that such
Improvements are not intended omffered tarsals.If,however,thebuilding or .TOTAL: s
Zee,
Lssold withinoneyearolcomph tior,theoemer-bullderwlll have
th¢Invdaen of proving that he did not build or Improve for purpose ofsale.). QTY;;,�I).'_��r PLUMBINGPERMITSt ''�` �' IIS FEE',' plppp ZDNE APN
LL-JJ L, s muni of the property,am exclusively contracting with licensed .
contractors to construct the project(Sec.7044,Business and Professions;Code: PERMIT ISSUANCE
The Contactor'.License law don not apply to an owner of property who - ALTER-DRAIN k VENT-WATER(EA)
builds or Improves thereon, and who contracts fee such pWjens with a , , .,. ,r.t -
co•B(pdor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE Il i,'FEE SUMMARY
L..I I am exempt under Sec. B k P C for this reason
Owner • - DRAINS.FLOOR ROOF,AREA,COND. ' - SANITARY V N
Date RECEIPT st
WORKMAN COMPENSATION DECLARATION pIX•Ng�PER TRAP SCIdOOL TAX Y N
0.7 hereby affirm that I have o lmurane o consent d epythevie,ora ' RECEIPT p
artlflatc of Workere'Compen+atlon lrsurance ora certl(Ied ropy thereof(Sec. - RK FEE Y N
3800,lab CJ T�t'19 39 GAA EA. .1�JE:417IT1'f �—. •I
Poiryp_ `"'L\��'11 T '�� . GAS EA.Sv -0VER4(FA) � ' RGCEQ'Tp
Co�mpanv Ri pre form[r / I BNLDINC DI ONFITS
f:S
ICcnificd copy lepercby fumlahed. GREASE ND •L WASTE l[d EP P ANCHECIC FEE
Certified cpy V filed with the city inspection division. //
' CERTIFICATE OF U1:MPT]ON FROM WORKERS' GREASE A N AID. rtYD
COMPENSATIOINSURANCE SEWER- ARV-STORM EA.200Ff. Rem t#
Date
Qhlsaectlon need not be completed the permit Isfor one hundred dollars
($10Lmless3 - - WATER HEATERW/VENT/ELECTR ENERGY FEE Y N
I certify that N the performance or the work forwhich this permit le insured,
I shall not employ any person In any reveries,n as to become abject to the tyA�g SYSTEM/TREATING Workers Compensation lawn of California.Date PAID
O Z Applicant
Z O NOTTCETOAPPLICANT;H,aftsroukingtN,CerofImteof Exemption,you NEW RFSIDENT}AL PLMB. SQFI'. Date Recei t#
should become subject to the Workeri Cmmpetu tion provisions of the Labor TOTAL:
WW Code,you=at forthwith comply with such provisions orthis permit shall be /
> deemed revoked. BUILDING ••E
IL G Co SEISMIC LENDING AGENCY SEISMIC FEE
Z Iherebyaffirmthatthem6aconstructionLendingagencyfortheperfmmm TOTAL: ELECTRIC FEE " app
M O once of the work for which this permit is issued(Sc.3097,Civ.C.)
V Lenders Name .. - PLUMBING FEE '
LL I- Lender.Address QTY. - 'y''';MECHANICAL PERMIT' :' FEE;' MECHANICAL FEE
O WIrenlfythatlhavereadthuapplimttonandstanthattheaboveinforrvtion .- MM
1 la rotten.Iagreemcompiywith allAtyand county ordinances and nate laws f PERMIT ISSUANCE f�.A•t/ FEE$PAID:
V) relating tobulldleg crstronlon,and hereby authorl:e representatives of this
Z city to enter upon the abovcnentioned property for inspection purposes. ALTERORADDTOMITH.
— (We . c to save,Indemnify an it keep harmless the City of Cupertino Date Receipt#
agal t a 11 -,judgmenta,c's it sea hich may leanywayaccme A!RMNDL1NCUMT(TOIO,000CF'M) SUBTOTAL:
ga City ncaaf the antro (this permlc ATRMNDLING UNIT(OVER IQOOOCFM) CONSTRUCTION TAX
�Itor Sate rte_
Si storeof AppBcAZARnlranor Date FJ(MUST HOOD(W/DUCT) ' CONSTRUCTION TAX PAID:
.. HA2ABDOUS MATE RIALS DISCLOSURE
Will the afi tied! ythefuture pbuilding onipalCstore de,Chapter handle
9.hazardoua HEATING UMT(TO 100,0000TU) Date Recei t#
rwterial as defined!bye SCupertino Municipal Code,Chapter 9.12,and the
Health and SafetyCotle Snnlmn 75532(.)1 HEATING UNIT(OVER 100,0110 BTU) ' t
Yes �No TOTAL:
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RRSID) ISSUANCE DATE'
which emit haeardous air mntamhunts as defined by the Bay Area Air
Quality Management Dislrin7 BORER-COMP QHP OR 100,0(10 BTU)
Yes
No
have read the haze usmalerials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) MAR
the California Health&Safety Code.Sections 25505.25533 and 2:534.1 r.a
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.Fr -
responsibilitytovotify the occupant of the requirements which must be met
prior to asua tics of a Certificate of Ottupznry. u6�0 A
al��tJ/L/y�{,i! � �—.,a7�
Owner or authorized a gent Date ISSUED BN`-"�xr�w-AlLll..4]'�-Q,
TOTAL:
OFFICE COPY ,