21571APPLICANT TO FILL IN INFORMATION WITHIN RED LINES USE BALL POINT PEN ONLY
BuildingProject Identification- I
Building Address: . - - . .
-� .L. ,��
PEILWT NO.
21571
1' one:
e4i Q • K •/� '
OwRea
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BU LDINGELECTR CALPLUMBINC-
- MECHAMCAL
A • A
edor'aNa uc.Nu
e e t Sd X00 Y
CATEGORY
COMROL N
Amhltect/Fsgineer; Lie. No:
QTY ' t ELEOI'RIC PERMIT '',1FEC
" -, t BUILDING PERMIT INFO,'' "
Addrav:, .r�/ (r�l"jy Qy- :. Lr G
PERMITISSUANCE "
�c�K�, �
E 'tlJ
-LICENSED CONTRACTOR'S DECLARATION
I herebysffirm that am licensed under provisions ofChapter9(mmmene
Ingwlth Section 7000)of Division 3o(the Bugnessand PerfesslonsCode, and my
Itmnse Is In (u fo d erred. {� (J,J°�
License/_(�LIeN
Data Contractor
ARCHITECTS DECLARATION '-
I understand my plav shall be usN u public records
Licensed Professional
' OWNER -BUILDER DECLARATION
Iherebyaffirm that l am exempt from the Contractors License Law for the
following reason. (Section 7071.5, Business and Professions Code My cityor
cmntywhichrequb aper ttommtmd,alter,Improve;dennlbh,ormpatr
anysructvrc prlorto its issuance,alse, exqulreslheappllcant forsuch permit to
(Ile a signed stateroom that he la licensed pursuant to the praWlons of the
Contractor's License Law(Chapter9(commencing with Section 7") of LTM.
grn3 rfthe Business and Professions Code) orthat he ha exemptthemfri
the basis for the alleged exemption. Any violation of Section 70715 by any
applicant for a permit subjectathe applicant to a civil penalty of not room than
five hundred dollars (fW.
❑ I, as owner of the property, or my employees with wages as the 4 wle
compensation, wllldothe work and the structure Is not intended or offered for
ssle (Sec.7014,'Buslnenaand Professlow Code: The Contractola Licery'2• Law
does not apply to an owner of property who builds or improves themes, nd
doessuchwork himselforthroogh Msownemployees, provided that* ch
fmprovemenlsarenot intended oroffered forsale. If, how ever, the building r
Impmver ntbsoldwitMnoneycarofcomplelon,theowner-builderwillha
thlL)urdenofpmving that he did not build rr Improve for puryose ofssk.j.
�uj I, as owner of the Property; am ezdusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Prafessloru Code:
The Contractors License Law does act apply to an at of properly who
Wilds or improves thomn, and who contracts for such ptojens wi
pursue
co tactor0) Rceneed pursuant to the Contmetla LE amLaw.
I am exemp under Sec. � B & P C (or thla mason
APPLIANCESRFSTDENTIAL
JOB DF_SCROxRON-
"
, * -
, PANELS
XII -1000 AMPS
OVER 1000 AMPS
SQ. Fr. FLOOR ARPA
1 ,
-
'
-
E/SQ. IT.
'
SIGNSEL CAL r
SPEFIAL CIRC T/MLSC
TEMP. M OR POLE INST,
p ipoWER
�
G ELECTRIC
O 7S ES
VALUATION
SQ'F'
STORIES
. TYPE CONSTRUCTION
_
-
-
TOTAL:
;�' .SPL BINC'PER MIT '�. ,' )FEE•',
P ErV ANCE
AL N6 VENT -WATER (EA)
OCC. GROUT'
-
F100D ZONE
RFS. UNITS
APN
BA W PROTECT. DEVICE
,,,.. FEE SUMMARY
- -- .,, .,.
Fel;
D NSFLOORROOF,ARF-k COND. `
FIXTURES, PER TRAP
• -
SANITARY Y N -
—
RECF1Pl'N -
Owner Date
- WORKMAN COMPENSATION DECLARATION"
❑1 hereby affirm that I have a certiRrate of consent to sol(-inwre, ora
380Lab of Workers Compematlonlruurance oraceril(led ropythemof (Sec.
3808. Lab C.)
Policy N
SCI100L TA% Y N_
RPCEI T N
GAS FA. SYSTEM-17NCAOUTLETS
PARK FEE Y N
RECEIPT X
GAS FA. SYSCEM-OVER 4 (EA) _
Como - Y _f�j
BUILDING DIVISION FE ES
ertlfied copy In heed withcity
❑Certified ropy V (Ikd with the tlty Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS•
' COMPENSATION INSURANCE
(rhlssedion need nat be comple,d if the permit la forom hundred dollars
(sIW)orlaxa.) •'
Icertify that In the performance of the work for which this perm it l is d
1 shag not employ any person In any rbinner m u tq p¢co pyb' the
Workers t employ auon U of G O. Date I eL r rl
-el �s�
CRFASEANOUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
DatC Recci t#
GREASETRAP
' SEWER -SANITARY -STORM EA. 200Fr.
wnreR l-[FA,T.en W/veN,1,/eLec.I.R
ENERGYFEE Y N —
PAID '
Date Recei t#
WATER SYSTEM/TREATING
' NEW RESIDENTIAL PI.MB. SQ.FT.
NOTApplICnt_I_Q
should TOMPLIC tothe ager rs'Co ehisxation ro o(Ez mpteLabu
Code, become curthwit the Work en' such provisions orthiovrmit shall
deamadou must forthwith comply with each proWloru orthla perms shall be
deemM revoked.
CONSTRUCTION LENDING AGENCY
I herebyarftrmthat there b a cowtructlon lending agency forthe perform'TOTAL:
ante of the work far whkh thb permit b Issued (Sec WW, CW. C.)
'Landers Name
Lendela Address -
Icertlfythatl have re ad thisapplicatlonand nate thattheabove information
lacorred. I agree to comply with all city and county ordinancesand gate laws
relating to building construction, and hereby authorize representativm of this
city to enter upon the above-mcntloned property for inspection Purposes. :
(We) agree to save, Indemnity and keep harmless the City of Cupertino
agalrutliabilties,judgments,mgsand expenses which may In anywayamue
ago ingt wld City in � granting of this permit
���.�0-
TOTAL:
-
BU IN •E
<
SEISMIC FEE
ELECTRIC FEE
'
-
QTY:'' MECHANICAL PERMIT: n",'°. FEE
PLUMBING FEE
MECHANICAL FEE
- -
PERMITISSUANCE �(,Zj
FEES PAID'- -
ALTER OR ADDTOMECH.
�'
Date Receipt#,
AIR HANDLING UNIT CrO 10,000CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,010 CFM)
CONSTRUCTION TAX:
a//v�A•%.�
Sigwtum of Applicant/Contractor oat
HAZARDOUSMATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous
materia I as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
Ilea lth a nd Safety Coda Sedlon 7S532(a)7
❑ Y. b No
Will the a ppllcant or futum building occupant use equl Froom or devices
which emit ha:ardma, air roma minants n deft red by the Bay Area Air
Quality Management District?
4 Yes No
have read the h. N materials requirements under Chapter 6.95 of
the California Health & Safety Code, Sections 25505,25533 and 25530. 1
understand that ltthr building does nm currently haveatenanq that it is my
prior to iwuance of a C dificate of O=pancy.
responsibility to roily the occupant of the requirements which mustbefret�990
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:-
AIDiHAZARDOUS
liFAT1NG UNIT (TO l00pp0 BM a.,�
aw _
Date: Reedt#
HEATING UNIT (OVER 100,OD0 BTU)
TOTAL:
A-
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE '
�d
-V
n`
V. 1
B 0
ISSUED BY: a
r 1 11
BOILER -COMP DHPOR 108000 BTU)
BOILER-COMP(OVFR 1(8,000 BN)
NEW RESIDENTIAL MEOi. SQ.Fr.
Owner or authorized agent Data
TOTAL:
OFFICE COPY