21426 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PFR.MITNO.
Building Address: 21 4 2 6
s(o fubr
'' ernns __ant�e^^:,^, ..--,^,'' on A A
�P—Z aM LI I af53 s3 CITY OF CUPERTINO-BUILDING DIVISION � ,Z—�^�
ntr d rat Name: �7 uc. a:/ APPLICATION /PERMIT
(o BUILDINGELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL N
rchitect/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PEPMITISSUANCE ❑ ❑ 11LICENSED CONTRACTOR'S DECLARATION
I Ferebyaffirms that lamsionsd under eBusinwland Pro ofChapter c APPHANCESRESIDENTIAL JOB DESCRIPTION
ingwlih Section7000)ol Di effect. the Buslnessand ProlesslanaCode,odd my
licensebin rat end effect. PANELS
License Lir.M---� �R'F'QO-IC
Date, -Contractor
ARCHITECTS DECLARATION 401-1000 AMP"'
p�p�uu
90 77,, I understand my plans shall be used as public records. OVER 10110 AMI'S SQ. FLOOR AREA $/SQ.FT.
Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION S('F-CIALCIRCUfT/MISC
fp, 7 I herebyaffirm that l amexemptfmmihe Contndor'sLlrenx Lawfmthe
70ZH� following reason.(Senlon 7m1.5,Businessand Prof.i r,Code:Anycityor TLMP.MLTPR OR POL NST.
cmntywhich requlrna permit tocomtroct,alter,impmve,deonlish,or repair
anystructure priorto its issuance,also requinothe applicant fee such permit to POWER DEVICES
file a signed statement that he is licensed pursuant to the provisions of the
Contractor's License Law(Chapter9(commencing with Section 700])of Divi- SWIMMINGLELECTRIC VALUATION
O slon3ofthe Businesaand Profs®lore Code)orthathel.om therefromand
the basis for the alleged exemption. Any violation of Sedloe 7031.5 by any OUTLETS TCHES-FIXTURES
applicant for a permit subjectsthe applicant toll civil penalty of out more than
five hundred delta.%S0( . NEW DENTAL ELECTR
7�n I,as owner of the Property,or my employees with wages as their sole SQFT. STORIES TYPE CONSTRUCTION
compensation,will clothe work and thestructure b nm Intended or offered for
p -In(kc.7614 Business and Pmfceska Code:The Contractor.License law
s$ does nm.pply torn owner,of property who Wilds or improves thereon,and OCC.GROUT' RIS UNITS
E who doessucliworkhimxUorthrough hhownemployme,providdthgsuch
Improvements arc net intended oralferd for sale.If,however,the W ilding or TOTAL:
improvement b sold within one ycamlcompletlon,the owner-bullderwili have
t4L4urden of proving that he did not build or Improve for purpose of sale.). QTY. PLUM G E p1.00D ZINE APN
u L as owner of the property,am exclusively contracting win Ilmnxd ppRMiTLSSUANC
rontnecton to construct the project(Sec 7014,Business and Professions Code:
The Contractor'.License law does not apply to an owner of property who
Wilds or Improves thereon,and who contracts for such projects with a AL -DRAIN6
gWfaetor(s)licensed pursuant to the Contractor'.License Law. BA FLOW IC FEE SUMMARY
c 1I I am exempt under Sm. B k P C for thin reasonOUTSIDE I LES
DRATR AREA,COND. SANITARY Y N_
• Owner Dace RECEIPT WOR KMAN COMPFT'SATION DECLARATION PERSCHOOLTAX Y N
rcure
by affirm that I have a oldifirate of consent to self-Ins ,ora mn�JWRFCEPf M
mer icateofWorked'Compensationlmurancemacedifk mpythereof(Sec. GAB ,SYSTEM-1 INCA OUTLETS PARK II Y N
P800,olicy# C.) O-� y��b'�(� � RECEIPT#
Policy# O CffGAS FA.SYSTEM-OVFR4( )
Cam any FABUILDING DIVISION FEES
Certified copy hereby furnished. GREASE/INDUSTRL WASTE RCFPTOR PLANCHECIC FEE
�ertified copy 6 filed with the elty inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-!!Oe EA 200FT Date Recei t#
(ThlssecHon need not be completed lithe permit Is for one hundred dollars
(51W)orles.) WATER HEATER W/ /ELECTR ENERGYFEE Y_ N_
1 comlythat in 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 WATERSYSTEM/ EATING
Workns'Campensationlawsof Cabfornb. Date PAID
O Z Appllcmt NEW RESIDP AL PLMB. SQFr. Date Recei t#
ZO NOTICE TO APPLICANT.If,after making this Certificate of F sropeon,you
Pe should becomsubject to the Workers'Compensation provisions of the Labor TOTAL:
CC0Code,you resat forthwith munplywltlesuch provisions orthls permit shall be BUI •
INC •
W _ deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Q. Iherebyaffirm that there is a construction lendingageneym,,he perform TOTAL: ELECTRIC FEE
DZ sore of the work for which this Permit is Issued(Sec.3097,Civ.C.) PLUMBING FEE
V O Lender's Name
LL F boider.Addrees QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I mNfythat l have readthb appliceticnand statethat the above Information
IL boomed.I agree to comply with all city and county ordinances and state laws PFRMITISSUANCE 12 OD FEES PAID:
r relating to building construction,and hereby authorize representatives or this
I.- U)
cityto enterupon the above-mentioned property fee inspection purposes. ALTFRORADDTOMECH.
_ Date Receipt#
(We)a t save,Indemnify an d keep harmless the City of Cupertino AIR IiANDLINC UNIT(x010,000 CFM)
V .93 til tie dgmenb,mets and expnnxa which may sr�anywayaceme SUBTOTAL:
agsinst e i nuquence of the granting of thin gerinf.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Sigrumme of Applicant/Contractor i Date IXFiAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) rQ�� Date RCCCI t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 4,and the
IBaln and Safety Code Section 45534(.)? HEATING UNIT(OVER 100,000 BTU) TOTAL: Z CJ3
Yes n No
Wllltheapplicantorfuturebulldingoccupantuseequipment ordevims VENTILATION PAN(SINGLE RFSID) ISSUANCE DATE
which emit haaniom air contaminants as defined by the Bay Area Air *-Win
Quality Management Distrid7 BOILER-COMP QHP OR 100,000 BTU) ��aG�
YesII'�No
have read the fuer. ous materials requirements under Chapter 6.95 of BOILER-COMP(OVERi c(L"BTU) DEC A 1 '
the California Health k Safeycde,Sections 75505,25533 and 2553/. 1 S 990
understand that if the building doe.not currently have a tenant,that It is my NEW RESIDENTIAL MECFi. SQ.FT.
responsibility to net iy the oro pant of the requirements which most be met V
prior to Issuance of a Certifiate of Occupa ney. �uv
OF Alft4olp
Owner or authorized agent Date O ISSUED BY:_
TOTAL:
OFFICE COPY