21913 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT KO.
Building Address: 21913
_ .5 l s c�e
area: ,.� one, CITY OF CUPERTINO-BUILDING DIVISION A
c° n or'aName: LIa.Na: APPLICATION I PERMIT 3 —� - R
C BUILDINGELECMCAT PLUMBIN6MECIiAMCAL CATEGORY CON]ROLN
Architectgineer. Lie.No:
QTY .ELECTRIC PERMITFEE BUILDING PERMIT INFO
Addrn Q ,�a
d y PERM TIBSUANCE ❑ ❑ ❑
LICENS EDCONTR under SDECLARATION L�
Ihereby dian7Ol ofDi OcnsedueBusinemand sof ChionsCocommen APPLIANCES-RESIDENTIAL JOE U1 Kll
Ingwlth5ett1an7000)cal Dlvialon3o(theguslnessand ProfessionsCade,and my
licenseisin(uB rte�ydd(ect. - r� PANELS Q
I.Icen la ° Cl Llc X G_-j E4 x'"'�'z� l
D Con nd.r UP TO 200ANTS
ARCHITECTS DECLARATION 201-IOOOAMPS
po+mO z I understand my plane shall be used n public retards. OVER 1000 AMPS 5C)�+L��s )�AR�� 5/SQ.F7.
E (O Licensed Professional SIGNS ELECTRICAL E� a"�
6 OWNEReBUILDER DECLARATION TER
R
IJn]a SPECIAL CIRCNT/MISC ` �, ••
7 f, owing y a on.(Seat l am exempt from the d Professions ode:anse Law y for city he or
polourtygreason.iecatan7031.5,Budnmand Professions Code:Any city or y2w/
/JI
ila1P.MEITR OR['OLE INST. 7
any simmerwhich requto ireea permit
ane,mrulmod,alter,requiesth Aprovgt foisuch,orir to
gP anyswdurcpdorreaIts lwaancgaW requires to the provisions
permit e ]OWER DEVICES AA'rE I
the a signed statement that M V licensed pursuant to the proWlors of the
Q63O� Contractor's License Law(Chapter 9(comstruing with Section 7000)of Divi. SWIMMING POOL ELEC'T'RIC
son 3 oflheBuslnsmand Pro(miors Code)onion he in exemptlherefromand VALUATION
the basis for the alleged exemption. Any violation o(Section 70X.5 by any
Q
applicant(Ora permit subjects the applicant to a civil pemlty afect cro.than OUILETSSWITCIffSFIXTURES
ed
five 1,as
rowner of
(e pm SQ.IT. fFlJO0D
TYPECONSTRUCTION
NEW RESIDENTIAL ELFLTR
d for
❑T,asownerll otproperly,ornd he employeswithwagesas thelesale
Z Q sale(5m.tion,Business wwKaesdomt odurehe is o Contraintenctors
or License
Law
O vie(Ser.70dg,w a now and Profmlore Code:The or impraves Licesse hw
$ does notapplyro en owner of property who builds arimprovsthcreoM and Rl'S UNITS
who dons such work himself orthrough his awn employees,provided that such 'N
Improvem.0mnotintendedoro(fered(orsale.lfhuwevepthebuitdingor TOTAL: LY
Improvement b sold within oneyearo(completion,the owner-budderwlll have
lelAmrden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT ..III. E APN
LJ f an owner of the property,am exclusively mntrading with Iimnmd PERMIT ISSUANCE
mntndora to mvteud the project(Seo 7006,Businm and Professions Code:
The Contractors License Law does net apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA)
Wilds or Improves thereon,and who contvds for such pta)eds with e
cg0tt actor(s)licensed pursuant to the Contractors License Law. FEE SUMMARY
LJ I am exempt under Seo B A, P C for this reason BACK FLOW PROTECT.DEVICE
OUTS I DE FEES
DRAINS.FLOOR ROOP,AREA,COND. SANITARY Y . N
• Owner ECL - RECEIPT X
WORKMAN COMPWSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N—
❑I hereby affiorkern that 1 have• Insurance
of consent m selop thereof
(Sa RECEIPT X
certificate of Workers Compensation lrsunnnaracertl(led copythereo((Sec. GAS PA SYSTEM-1 INCA OUTLETS PARK FEE Y N
Polk lab C.)
cc an n GAS EA.SYSTEM-OVER 6(EA) DING DI X
Y BUILDING DIVISION PEES
edified copy is herebytumecity GRFASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
Certified copy V(fled with the city inspection division.
CERTIHCATEOF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SAMTARY-STORM EA 200FT Date Recel t#
(This section need era becomplctedBtM permit V torose hundred dollars
(SI 00)oWATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Isthat the performanceof thework nrwhich this Permit hm
Issued, —
1 shag not certify
no employ
at
y any person In any manner as t0 berome subject to the WATER SYS'TFM/TREATING
Workers'Compensatlan hove of California.Date' PAID
O Z Applicant NEW RESIDENTIAL PLMB._SQFT, Date Revel til
Z O NOTICE TomesubGANT:If eller making this Certificate°(Exemption,you
should become subject to the Worken'Compersatlon provisions of the Labor - TOTAL:
(/) Code,you most forthwith comply with such provisions or this permit shall 4 LNG '
dermad revoked.
W G CONSTRUCTION LENDING AGENCY SEISMIC FEE
EE
CL Iherebyaf(irm that there Is a construction lending agency for the perform, ELECTRICPEE
M Z ance ollhe work for which this permit is Issued(Sec.3097,Civ.C.) TOTAL:
U O ..dors Name PLUMBING FEE
LL I- Iandcea Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I cerifythat I have mad thisapplication and statethatthe above information
is correct.l agraeto compiywith all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} a ;.Itingmouildln cotstroctlonend hereby authorlu representativn o(thb to enteru .abve-mentioned property for inspection purposes. ALTERORADDTOMECH.
? (We)a e to save,Indemnify an d keep harndese the City of Cupertino Date Receipt#
isst IBtlee,}adgments,metsande wNchmayInanywayamrue AIR HANDLING UMT(TO 10,000 CPM) SUBTOTAL'
i Id City in comequence of t goft epermlt.
Z AIRHANDuNCUMT(OVFR ieoilocfm) CONSTRUCTION TAX
of ex VC. ams. Dae - EXIIAUSTHODD(W/DUCT) CONSTRUCTION TAX PAID:
HA OUS MA TERIALSDISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO IW,000 BTU) Dale Recei t#
material as defined by the Cupertino Munlcipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(a)I HIu1TING UNIT(OVER 100,000 BTU) TOTAL:
❑Yee I]No
Will theapplicant or future building ocmpant use equipment ordevices VENTILATION IAN(SINGLE RESID) ISSUANCE DATE
which emit hauMous airconlandnants as defined by the Bay Ars Air
Quality Management District? BOILER-COMP GHPOR 100,DM BTU) PAID
4 Ys N No
havercad Health
a fet mmerlab tions2renteund 5505,25533 and 25534.
of BOILER-COMP(OVEIt 100,000 BTU)
the understand
Health bSafetyCode,not
currently
vesternd,that 1 MA 12 1991
understandyton tify the ing occupaat not erreuirecr at a which that Ttlimy NEW RESIDEN77AL MECH. SQ.FT.
prior
responsibility to edify the occupant of the requlrerrente which most be met
prior to Issuance d a Certificate of Coca panry. "
My of.Cuper' ^n
Ownerorauthmieed agent
Dere ]OTA L: ISSUED
OFFICE COPY