21081 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Protect Identification _ PERMIT NO.
Building Address: 21081
p i+c
m: Ph e A
ov,,/ (foci Lys', y") CITY OF CUPERTINO-BUILDING DIVISION q��-qD
cono-adnrs Nzme: Lk.N. APPLICATION / PERMIT 1
<1�4Ll6N��j BUILDINGELECTRICA PLUMBING.MFCH LAICAL CATEGORY
Lie.No: (Ipp CONTRQLJGG..���-
Architect/Engineer.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
T herebydt7OOD) fDiAl ensed 3ofthe er ugmvisions and Pr(Csslons9de,and APPLIANCESRESIDENTIAL 109 DESCRIPTION
1ngweM1 Inful1jpcea !eft on7oflhe9udnnsand Prc/aelonsCode,and my I
license is In fail rce and died. PANELS
Lire.Cls Lu.N
Date Contractor
ARCHITECT'S SIR D 201-�pM �
pQ±rs02p fund rand my plata sisal s. OVER IOWJ SQ.FT.FLOOR AREA S/SQ.FT.
E (/ LI¢nsc SIGNS ELECTRICA
lni'+ R-BUILDER DECLARATION SyEC]ALCItCU1T/tMLSC,
Zt, � the a( thelamexemptfromthe Contractor's License Law for the
OO (oBowing rearm.(Section 7031.5,Business and Profession$Code:An e or
O Z f: Y t1' TEMP.METLIt � POLE IN
KSI county requlresapermitWcomtmct,alter, demollshorrepalr
< ateis ny structure prior to its haus me,also requires the appliant for such permit to
DEVIGF4W ,�
W V ale a signed stament that he licensed pursuant to the provisions of the
BOwI� Contractor.License I..(Chapter9(commencing with Semen 7000)of Divi-
OJ van.3ofthe Butlnessand PreemlmoCode)orthat he ise•emptthmefromaM MTNG7?OOL Ef.^&SV4ERIC VALUATION
�'•77 the bash(or the alleged exemption. Any WolaHon o(Smtbn 7a3LS by any �s
< applicant fora permltsubjeentheapplicamttoa civil pemlty ofnet morethan Off' FI ES00
five hundreddollarshe pro NEWR ELEC SQ.FT. STORIES TYPECONSTRUCTION
ecompensation,
owner of the property,or my employees with wages act their sole
C com(Se.7 KBusdothe ss;and rendthestmaturehtCHtractodoromese l for
Law
xy O sale(Sec apply to Business;andProfessions
property Code:The Conorimprtols Gceme Law
p $ whoddors oessuch loan owner o(proughhisobuilds nemporimprovesihercoryand OCGGROUP RES UNffS
0. wrprov, aucbwork Mmself ndedoroffe Msowne.1f,h ee,provided
,theb thatsuch
m
Improvemodiare n¢intended orolfered tereah.If,however, ilderwdingve TOTAL:
Improvementissold withlnoneyearo(compldbrytheowner-bullderwlll have
tlWL urden of proving that he did not build or Improve for purpose of gods.). Cry. PLUMBINGPERMIT FEE FLOOD ZONE APNr
Lj Las owner of the property,am sethnd sly contracting with licensed PERMIT ISSUANCE
contractors to comtmet the project(Sec.7014,Business and Professldm Code:
The Conted¢.License Law does not apply to an owner of property who (FA)ALTER-
builds or improves thereon, and who contra for such pUojects with a DRAIN&VENT-WATER
ME,
licensed pursuant to the Contractor. FEE SUMMARY
License Law. BACK FLOW PROTECT.DEVICE
LJ T am exempt under Sec. B&P C toe this reason
Owner Date DRAINS.FLOOR ROOF,AREA,COND. _ SANITARY Y N—
— RECFL N
WORKMANCOMPENSATION OECLAR.ATION FDCIURFB PER TRAP SCHOOLTAX Y N
❑I hereby affiork that I have a cerci m of consent to pytheure,ora RECEIPT N
cemi0¢teo(Werken Compematlonlrouran¢¢acenifled copy themo((Sec. GPS,EA.y-YbTFA1.11NC40VILEIS PARK FEE Y N
3800,Lab CJ
Co CAS-
M G 2�A RECEIPT M
CAS F.A.SYSTEM-OVER BUILDING DIVISION FEES -
e Bled copy h hereby furnished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified mpy Is tiled with the city Inspection division.
CERTIFICATE OF O(EM"ION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA 1001-!. Date
(Thlssectlon need mat be completed if the permit h(prom hundred dollars t
(S100)¢less.) WATER HEATER w/vENT/ELECTR ENERGY FEE Y N
l u milythat In the per(ornan¢of lhew¢k for which lMs permit b Weed, —
I shall not employ any person In any manner an as to become subject to the WATER SYSTEM/TREATING Workers'Compensation Laws of California. Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SOFT'. Date Recel t#
Z NOTICEco esubjeAM:H,aRerrs'Comer making I his Certificate o(Ens of the
you
Code,shoulou=st ubjewith to co Work en'such pro,bonpmvbiomrmit s Lab be TOTAL:
N deemed revoked.forthwith comply with such provi$iom orchis permit shallbe
j deemed revoked. BUILDING FEE
W
p CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby aftlmnthat there is a construction lending agency for the perform,
M Z ante ofth.work for which this permit b TOTAL:btted(Sm.3097,Civ.C.) ELECTRIC FEE
02 lender.Name PLUMBINGFEE
LL t— Iender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W
boomed.
have read thhapp9¢donandstatethattheaboveinformation
med.I agree to complywith all cityand county ordinances and nate laws PERMIT ISSUANCE FEES PAID:
} N relating to building comtmctlory and hereby authorize representatives of this
Z city to enter upon the above-mentioned property for lupectlon purposes. ALTER OR ADD TO MECH. Da1C Recei [#
I..I (We)agree to save,Indemnify an d keep harmless the City of Cupertino AIR HANDLING UNIT RO 10,000 CFM) ' P
agalrutllabilitles,judgments,code end as rases whlchmayinanywayamue SUBTOTAL:
a told City consequeme.fth a ling dthl$ t.
a AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Signa reo(Appb unit Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
MATE DISCLOSURE
Willthe e-1 re gmeopantstoreorhandlehazardous HEATING UNIT(TO 100,000 BM
matcrhlasdef, y upertino Municipal Code,Chapter 9.11,and the Date Recei t#
Health and Safety cod Section 75531(a)7 HEATING UNIT(OVER 100,000 BM TOTAL: (,
I-1 Yea I`l No
Ilenut hazardous tor
tom mina is as defl ndbyt use equipment or devices VENTILATION PAN(SINGLE REED) ISSUANCE DATE
whicheManagement air contaminants act deaned by the Bay Arca Air PAM Quality Management District? BOILER-COMP pkEr DR 100,OW EM [—./'VCS
Yes ❑No
4haaz
vereadthehaWousmaterialsrequirementsunderChapter6.95of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Smile.25505,25533 and 15534.1
u ndenta nd that if the building does not currently have a tenant,that Itis my NEW RES!DENTTAL MECH. SQ.FT
respprior to Issuance
a c notify theoccupantofthe¢qulrementa which most be met
prior to issuance ni a ythe mee o(Ocapa reqacy.
Owner or authorized agent Date ISSUED BY:��
TOTAL:
OFFICE COPY