21959 (2) APPLICANT TO FILL IN INF RMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ce Identification PERMIT NO.
Butldln�:dd a: , _ Ile, 9 _ 21959
sera. m: on . _ A A
a CITY OF CUPERTINO-BUILDING DIVISION
eptra n',N•m= APPLICATION I PERMIT O ' l
C�F[QL� BUILDINGELECTNCALPLUMBINGMECH LAICAL CATEGORY CONTROL x
Amhlte t Englneer. Lk.No:
_ CITY ELECTRIC PERMIT FEE BUILDING PERMIT INFO,
Address-9 - _- - - PERMITISSUANCE ❑ ❑ ❑ �X
LICENSED CONTRACr R'S DECLARATION �J
I hereby affirm that l am(maxed under prwlslonsof Chapter9(commme- APPLIANCES-RESIDENTIAL JOB DFSCRB'I'ION
license
13 In fon forced deffeon3 o(the Businessand Profesdons Code,and my
license isms force and effect. PANELS
Llcenx Class Cell
Date GOtOtar
ARCHITECTSDECLARATION 201-1000 AMPS
re0O
Z I understand my plan shag be used u public records OVEROVER IOW AMPS SQ. 'I.FLOOR AREA S/SQ.FL.
C
t, Licensed Professional SIGNS ELECTRICAL
<ul OWNER-BUILDER DECLARATION
DI $I'ECWLCIRCUIT/M15C
l., P Itureowing rason.(hatlameaempt.Busiessad PrxxftoriLitnx Lawfa the
O2F
following reason.(Setlon 70015,Business and ProBabns Code:Mytlty or TEMP METER OR POLE INST.
county which requires a permit to construct,alter,improve,demolish,or repair
F 1��Cat any stmcture prior to its Issuance,also requires the applicant for such permit to POWER DEVICES
K1 file a signed statement that he Is licensed pursuant to the provisions of the
3 a Contractor's License law(Chapter9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
X05 deal)ofthe Buslnessmd ProfessionsCoclOorthat he b exempt therefromand
•] the basis for the alleged exemption. Any violation of Section 7MI.5 by any OUILETSSWITCHESFIXTURFS
applicant fora permit subjects the applicant to a civil penalty of notmore than
five hundred dollars($5M. NEW RESIDENTIAL ELECTR SQ.Fr. STORIES TYPE CONSTRUCTION'
❑I,as.war of the property,or my employees with wages as their sole _
F. compensation,w0ldotIuvnrk andthestruture isnotletended car offered for
^S sale(Sec.7644,Busim.and Profewlav Code:The Contractors License Law
(;j3$ docs not apply tom owner of property,who builds or Improves thereon,andOCG GROUT' RIS.UNITS
CC.. whodoessult workhfted1forthrough hbown employees,provided thatach
improvements art not Intended oroffered formic.If,however,Ihebuilding or TOTAL:
Improvement b sold within oneyearof completion,the owner-bullderwlll have
ty�arden of proving that he did not bulla or Unprove for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOODZONE APN
LI L as owner of the property,am exclusively contracting with Iitnsed PERMIT ISSUANCE
contractors to construct the project(Sec 70K Business a"Professlons Code:
no Comment's License law does not apply to an owner of property who
builds or Improves thereon,and who contracts for such plvj is with a ALTER-DRAIN&VENT-WATER(EA)
TI
licensed pursuant to the Contractor's Llcenx Law. BACR FLAW PROTECT.DEVICE FEE SUMMARY
TJ I am exempt under Sec B&P C for this reason
OUTSIDE FLCS
DRAINS FLOOR ROOF.AREA.GOND. SANITARY Y_ N_
Owner Date RFiCOPI'N
WORKMAN COMPENSATION DECLARATION pD(TURES PER TRA(' SCHOOLTAX Y_ N_
❑I hereby affirm That I have a certificate of consent to self-Insure,ora RE-.CEIT T a
mtificate ofW.rkenOC..pv."..l�mance r.certified copy lhereof(Sec. GAS EA.SYSfEM-1 INCA OUTLETS PARK FEE RFGEBN
1,W,Lab ) Q /j
I � -- CAS EA.SYSTEM-OVER 4(EA)
Lk_ BUILDING DIVISION FEES
Certified copy Is hereby famished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
❑Cetified copy Is filed with the city inspection division.
CERTIFICATE OF OKEMPFION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FE. Date ReceI t#
(Thlesectlon need net be completed If the permit bfor ane hundred dollars
(S100)orlmsJ WATER HEATER W/VENT/M TR ENERGY FEE Y_ N_
I ormlythat In the performance of thework furwhich this permit Is issued,
1 shall net employ any person In any manner so as to become subject to the WATERSYSTFM/TREATING
Workers'Compensationlaws of California Date PAID
O Z Applicant NEW RESIDENTIAL['LMB. SQFr. Date Recei t#
Z NOTICE TO APPLICANT.IL.fer making this Cetelcam of Exemption,you
0 should became subject to the Workers'Compensation provisions of the Labor TOTAL:
H N Code,you must forthwith comply with such provisions orthb permit shall be BUILDING FEE
IIIW m
> Bernard revoked.
— CONSTRUCTION LENDING AGENCY SEISMIC FEE
a ° I hereby affirm that there is a construction lending agency for the performELECTRIC FEE.
7 Z arm ofthe work for which this permit b bound(Sec.3097,CIv.C.) TOTAL
00 Lenders Nam PLUMBING FEE
LL I— Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W omet. tageretvemply wappBcitiandcoundate
yorolar,:eddbReIion I•EFa$IrA (t
1 lacorretl.Ihat Ihae read twithall tltiondcountyhatthea! and turns PERMIT ISSUANCE 2.f�U1(_ I-`lll—
N relating to building construction,and hereby authorlae representatives ofthb ALTER OR ADD]'O MECH.
(_ Z city to enter upon the above-mentioned property for Inspection purposes. Date CCCIPt#
_ CiVe)alpectosave,inclemadlyand keep harmless
CaCupertino
agaWtBabiliticdgmenls,,"sand expenses which mayn n wayacave AIR HANDLING 1NR(x010,000 CFM) SUBTOTAL:
agaiat/sJ��((�acW In m� f grmtmg of ova permit. CONSTRUCTION TAX
iy/J'�" s__1 4 AIR HANDLING UNIT(OVER 10,000 CFM)
C/d:LI%✓.Af'�f ?_ !1— EXHAUST HOOD(W/DUC'q CONSTRUCTION TAX PAID:
Signature of AppgcentARDOator Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant alone or handle hazardous FSFATIIRC UNIT(TO IW,000BII)) Date RCCCI t#
ruderlal as deft ne i by the Cupeti no Municipal Code,Chapter 9.1 2,and the
I Ieakh and Safety Cade Section25532(a)i ([EATING UNIT(OVER 1 0),000 BTU) TOTAL:
I-1 Yes No VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
Ill the hppemt m future m1n.at.occupant use equipment or devices
which eManagemnt District? nanlsas defined by the Ray Area Air ern
Quality Management District? BOILER-COMP O}Er OR 10),0(9 BTU) Esu
4Y. No i
have read the F r�O sratcriabrequiremcnbundcrChapler6.95of BOR ER-COMP(OV[A1W,000BM
the California Health&Safety Code,Sections 25505,c25S33 and 25574.1 NIAR 22 1991
understand that if the building does nod currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Fr
responsibility to notify the occupant of the requlrarcnls which must be met
prior to issuance t a Certificate of Occupancy. of
„4V �l.ri Tlo htN
Owner or aulhoriud agent Date ISSUED 6YL
TOTAL: JAW
1
OFFICE COPY