21005 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USEBALL POINT PEN ONLY .
Building Pm'ed Identification 77 PERMITNO.
Building Address: . - - 21005 :Chv
o sTo ices
ane: one:
^e. , l.�loa �1146l64 CITY OF CUPERTINO-BUILDING DIVISION Q_1-Z
contndor'n aces: a='Nnr
6 `
APPLICATION I PERMIT' 6 l
�N V�'s'a a+ BUILDING-ELECTRICALPLUMBING-MECIIAMCAL CATEGORY CONTROL N
Archited/Engineer. LIc.No. "
Qiv i•ELECTRICPERMIT� tFEE � •{�'" BUILDINGTERMITJNFO `
Addmas:- _ PERMITISSUANCE - r ❑ ❑ N PLUMB M�H
'. ❑ '.
LICENSED CONTRACTOR'S DECLARATION
(hereby affirmthat lam Recosed under provisionsof Chaptcr9(commenc- APPLIANCFSRESIDENTIAL ]OB DESCRIPTION'
ingwlth5eedon 7000)of Divislon3ofthe Bwineesand Proeffee, �f°essions Code,and my
in
LI neo CbsE/7LICY.. G Q i� .1.. PANELS .
Datq?—tj-6n._Conemclor, ._� Vpg6� \J -
-{ '-1 C ARCHITECT'S DECLARATION 201-1000 AMPS '
qflq�GG
+ , I understand my plain shall be used as public recomis. OVER1000AMPS SQ.IT.FLOOR AREA 8/SQ.FT.
k Licensed Professional SIGNS ELECTRICAL - -
Q OWNER-BUILDER DECLARATION
SPECIAL CIRCUIT/MISC
p 7 °I herebyalirrri lhallem exempt fromthe Contrador'elimns Law lrn the - '
-02 8 following reason.(Section 70115,Business and Professions Code:Any city or TINP.METER ORPOLEINST.
rf, I" county which requires a permit tocostrod,alter,Improve,demollsh,oreepalr
d- anystmcture prior to its issuance,also requires theapplint fwsuch permit to POWER DEVICES
5 Innsa signed statement that he b licensed pursuant to the provisions of the -
HnContractor's License law(Chapter 9(commencing with Section 7000)of Divi.
sion3ofibe Buelneaiand Profeslons Code)orthathelsexemptthemfmmand SWIMMING POOL ELECTRIC EVALUATION
6 5 the basis for the alleged exemption. Any violation of Section 7031.5 by any OIJ7LETSSWITCHESFIXTIR2E5
applica tfora permit subjects the applicant to a civil penalty of net more than
(ave hundred dollars(x500). - NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPECONSI'RUCTION
�n ❑I,as owner of the property,or he employes with wages r thele sole
C compensation,will do the work,Pocdes lhesCde:TheCure is Contraintendctorsffered for
5 O doe(oot.70Kpply 1.Business wandf property
Code:The Contractorsthe. Law ---
�jS$ don out apply torn owner ofpropertywhobuildsorImprovethereon,and
- OCC.GROUP RES UNITS
who
ovem nts workam not
tintelf ndedoruogh hbow formic.
If, p theb that such
improvementsmold ithindoyearfseedpletion,thehowever,ctheerwillng or have - TOTAL: _
improvement within one yearafcompletion,the nurser-WRderwlll have
t ben of proving that he did not build or improve for purpose of sale.). QT'Y.',0 •'PLUMBING P,ERN6f,',t'91t"' .1`t EEB.; FLOOOMNE APN
I,as owner of the property,am exclusively contracting with licensed PDiMIT ISSUANCE- -
and I dom to modruct the project(Sec 7044 Business and Profeslons Code:
The Contractors Limew lAw don not apply to an owner of properly,who ALTER-DRAIN&VENT-WATER(FA) _
Wilda or imp mms thereon, and who contracts for m -
such Inppwith a �tl � . FEE SUMMARY
cottj'dor(e)Ilcensed pursuant to the ConmadoraLlmnm Law. BACK FLAW PROTECT.DEVICE '��'
LII am exempt under Sec. B&P C for this reason
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner. Date RECEIPT p -
WORKMAN COMPENSATION DECLARATION
'MI hereby a!(irn that!have a artiRcete of consentto slf-Isere,w FJXTURES.PER TRAP SCHOOL TAX Y N
a R E[PT M
cent(Irateo(Worken'Comperwtlon Wunnm mramrti(led copylhemof(Sec. GAS LEIS FA.SYSTEM-1 rNCAOUTPARK FEE Y N
_
RECEIVr#
Policy 11 GAS-EA.SYSTEM-OVER4(EA)
' Cam any � - - BUILDING DIVISION FOES
ffCertlfted copy is hereby fumished. - GREASE/WDUSELL WASTE INTERCEPTOR PLANCI'[ECK FEE
[]CenlBed copy is filed with the city inspection division.
CERTIFICATEOFEKEMPTION FROM WORKERS' I GREASE TRAP PAID,'
COMPENSATION INSURANCE - SEWER-SANITARY-ST'OAM G.200FC. ° DBT¢ RCCCI IN
(Thlssedian need not be completed If the permit isforone hundred dollars
(f1 W)or les.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N—
I certify that N the performance of the work for which this permit is Issued,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workcrs'Compensation laws of California. Date .PAID
0 Z. •..Applicant NEW RESIDENTIAL PLMB. SQFf. ' . Date Refer t#
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provhima of the Labor TOTAL:
W Code,you most forthwith comply with such provisions,or this permit shall be -
LU j deemerevoked. Py P - BUILDING FEE
W — .CONSTRUCTION LENDING AGENCY SEISMIC FEE
D. - 'Y hercbyafftrmthat them Is,amretmdlon lending fort he perform, IL/�x ELECTRIC FEE
Z once.1 the work(or which this permit B bred(Sec.3097,Civ.C.) TOTAL:'
0 O Lender'.Name - PLUMBING FEE
LL F Lveder'c Add. - QTY. `MECHANICAL'PERMIT • F'EE' MECHANICAL FEE
0 O Irnnifythat I havemadthb applicatbnand stmelhat the above Information -
.LLIaIsmrred.I agree to comply with all city and county ordinance and state laws PERMITISSUANCE FEES
PAID:
city to globuilont ronovewenn,andherobyrty,or@erepresnpurpos o(this
H N dt(Wo)aeree to the,inde-memioned property, Wpe Cit purpose. ' ALTER ORADDTO MECH.
? (We)agree to sue,IndemN(y an d keep Mammies the City of Cupertino � Date ." RCCe1Pt41
V
againstlabllitin,jadgmente,coanand espensn which ray In any wayamue AIR HANDLING UNIT 8010,000 CFM( SUBTOTAL:
:ag sulci City,ln nae of the granting of this permit -
Q AIRHANDLNGUNIT(OVERI0,000CIM) CONSTRUCTION TAX
Ignaturc o(Applleint/Cont i' ^!Date E%ILAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appR=ant or future bulidingonapant store or handle haxardous HEATING UNIT CFO 100,000 BTU) Date' RCCCI Ile -
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
'
Health and SafetyCock Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: car
-Ycs No , . .
Will the applicant ogturcbulidingoccupantuse equipment ordevlces VFNIILATION FAN(SINGLE IiFSIW ISSUANCE DATE
-which emit havardous aur mnlamioams as defined by the Bay Area Air
Quality Management Dlstrid7 BOILER-COMP pHPDR 100,000 RTU)
Q
n Yea QNo
pm
f1
the California
�9 4havcread the hazb ardous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) ,. cell '
Health&Safety Code,Sections 25505,75533 and 75534.I
uSE"
understand that if the building does not currently have a tenant,that it my NEW REST DENTIAL MECA, SQ.Ff f O 1
msposoccupantreq
ibllity to not lfy t he occupant of t he ub
emants which=at be met �a l990
prim to Issuance of a Corti fiette of Ocetpancy. -
C°
Owner or authorimd'agent Date - - - ISSUE.OR
OL:
OFFICE COPY