21401 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'en Identification PERMITNO.
Building Address: /� A O a�
20735 �feVe>J�S Uo�� g�✓�. G 4 I
e one: AVI'LICA HUN SUBMITTAL DA 11
'Pje p60.�b CITY OF CUPERTINO-BUILDING DIVISION
Contraaor'sNem,51r Que.Ne: APPLICATION /PERMIT
BUILDING-ELECTRICAtePLUMBING-MMHANICAL CATEGORY CONTROL
Architect/Engines Lie.No:
1 ,I 0 /a r)/1 QTY, ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addrem: �✓� /i0'HJ';-gm;5-r SS (� PERMITISSUANCE ❑ ❑ TrM
❑LICENSED CONTRACTOR'S DECLARATION ICJ
I hereby affirm that l am licensed under provisions of Chapter 9(comenenc- APPLIANCESRESIDENTIAL J08 DESCRIPTION
with Section 7000)of Division 3 ofthe Business and professions Code,and my - �r G�s
ilcensc ie in full fo end effect. ' PANELS G
Llcene Cl m Llc p
Date�Contractor 1 j A)r UP TO 2DO MAPS
ARCHITECT'S DECLARATION 201-IOOOAMPS
flfl2 I undemtanl my phrueluBbeuaed as public moreds, JOVERIODDAMPS SQ.FL FLOOR AREA S/SQ.FT.
O
Licensed I'm easloml SIGNS ELECTRICAL
6 OWNER-BUILDER DECLARATION
Ci SPECLILCIRCUIT/MISC
1 hereby Zt, owingraon.(Scetlam31.5,Business tromthe Contractor'sLicense Gov fns the
following reason.imoo n 7N1.5, mtmd and professions Code:Any city it
O � TEMp.METER OR POLE INST. .
any atrocturetatemeltahnuance,licensed
to
pronasions of rtto
e POWER DEVICES
O � Rlc a signed statement that he b Borne d pursuant to the previsions of the
Contractor's License Law(Chapter 9(commencing with Section 7000)of Dlvh-
H�OS shin 3 ofthe Buslaudeand Peofexkes Code)orthat halt exempttherefromand SWIMMING BOOL ELECTRIC VALUATION
yy the bselefor the alleged exemption. Any violation of Section 70115 by any
605 applicant for a permit subjects the applicant to a civil penalty of not meridian OUTLETSSWITCHESFD(TUR
IS
five hundred delta.($500), NEW RESIDENTIAL ELEC STORIES 1Yl'E CONSTRUCTION SQ.FI.
F-1 1,as owner of the property,or my employees with wages as their sole
compereation,whll dothe work and thestruRure is not Intended or offered for
OsatofSec.7044,Businessand Profemiona Cod¢The Contradoes Llcene Law
032 docs not apply to an owner of property who builds or improves thereon,and OCC.CROUP RFS.UNTTS
who does such work himelforthreugh his own employees,provided that such
improvements are not intended or offered for sale.If,however,the building or TOT
Improvement baeld within omyearofcompIMl mtheowner-builderwlll have
the burdenof provingthat he did not build or improve forpurpoae classic.). QTY, PLUMBING PERM I FLOOD ZONE APN
U 4 as owner of the property,am exclusively contracting with limned PERMIT ISSUANCE
contractors to construct the project(Sec.7014,Bueinem and Limitations Code:
'Die Contractor's License Law does net apply to an owner of property who ALTER-DRAIN VENT-WA
builds or improves thereon,and who contracts for such ptojecb with a
co6actor(s)licensed pursuant to the Contractor's License Law, BACK FLOW PROTECT.DEVICE FEE SUMMARY
I_J I am exempt under See. B&P C for this reason
DRAINSFLOOR ROOF,AREA,GOND. SANITARY Y N
• Owner Date RECEIPT 0
WORKMAN COMPENSATION DECLA RATION FLYNRE&PER T SCI{OOL TAX Y N
❑I hereby affirm that 1 have a certl0ate of Co..m to self-instant,or a R te,s
artl0czte of Workers'Compensattonlescrance ora certified copy thereof(See. GAS EA.SYSTEM-1 O[TIL
3800,Lab C.) ARK FEE Y_ N
Policy p GAS G.SYST¢t1-0VER 4(EA) RECEIPT M
Co������mIIIlppuuuCer BUILDING DIVISION FEES
91Certi(Ied copyhhercby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECIC FEE
Certified ropy h filed with the city inspection division.
CERTIFICATE OF EKEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWERSANITARYSIORMEA200FT Date Recd ted
RMssecHon need notbe completedlithe permit ltIonone hundred dollars
(f100)orfem.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I snotify that len the peciomnanceofthe work for which this permit
subj subject
the —
I sore not employ any portion in any manner n m to become subleR to the WATER SYSTEM/TREATING
Applicant
Workers'Compensation Laws o(Glifomh. Date PAID
O z NOTICE
Date Remi tN
Z O NOTTCE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDLNTIAL PLMe. SQ.Ff.
should become subset to the Workers'Comperuatlon provhhom of the Labor TOTAL:
cc In Code,you oust forthwith comply with such provislom orthh permit shall be
j deemed revoked. BUILDING FEE
W G CONSTRUCTION LENDING AGENCY SEISMIC FEE
d I herebyafRrmthat there h a construction lending agency for the perform, ELECTRIC FEE
Z and eftha work for which this permit is houed(Sec.3097,Civ.C.) TOTAL:
02 Lender.Name PLUMBINGFEE
LL ~ Lender'.Address QTY. MECHANICAL'PERMIT . FEE MECHANICAL FEE
OW I malfythat l have read the,appliationandstatethatthe above Information
a bcorrect.Iagreetocompiywhthallcityandcountyordinanmaand0a/elaws PERMIT ISSUANCE FEES PAID:
} N relating tobullding construction,and hereby authorize representatives ofthh
1.. Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADDTOMECH. Date Retel [#
_ (We)agree to save,Indemnify an d keep harmlem the City of Cu pen Eno
agahnatllablbtiegpdgments,callsandexpen.n hichmayinanywayaccrue VFZ AIRHANDLINGUNITT17010,000CFM) SUBTOTAL:
a a twit Cltyincon nae hegaimagofthfspe It
AIR HANDLING UNIT(OVER I0000CR.) CONSTRUCTION TAX
Sig alure ofant/Contractor - Date IXHAO57I[OOD(W/DUCT) « CONSTRUCTION TAX PAID:
HAZARDOUSMATERIALSDISCLOSU E s
Will the applicant or future building occupant store or handle hazardous 'L HEATING UNIT(TO 100,000 BTU) 10$,e2D Date RCCCi t#
material as de0rsd by the Cupertino Municipal Code,Chapter 9.1$and the
Health and Safety Cade Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Y. No x 9
Will the appBantor usacquipment the Bay Area
devices VFN71IAlTON PAN(SINGLE RFSID) IS$UA
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP(3IB'DR 100,IX13 BTU) AV g�
4Yes ❑❑No 10 1
havereadtha bazedeus materials requirements u nder Cha pier 6.95 of BOILER-COMP(OVER 100,000 BTU)
the Cahfomh Ilmlth&Safety Code,Sections 25505,25533 and 25534. I '
understa nal that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQk7 Me Of
resporeahility, and
notify the occupant of the requirements which must be R v Y.{q"(f7NlfayW
pdor to lt uame of a Certificate of 0cc pancy, s(-1
Owner or authodud agent Data ISSUED BY:
TOTAL:
OFFICE COPY