21744 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingProject ect Identification PERMIT'NO.
B°"din Addtca ,: _ r� 21744
1 wrier.J� qy6 /'ivC C3cooi< < T �rl �4 /j LT
ame. .r one: APPLICATION SUBM11TALw
f`(Gie 11P CITY OF CUPERTINO-BUILDING DIVISION0, I ely
/ 5/
o-aR aNa ,/ �L' APPLICATION / PERMIT /
�f 'r Vs/L BUILDINGELFICTRICALMU BINGMFLFIANICAL CATEGORY CONTROL
ct/ ghee r LI N
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add rea> PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(mmmene, APPLIANCES-RESIDENTIAL JOB DFSCRI'TION
ingwith Section 7000.l Divislm 3ofthe Bumnnsand Pmfes•IomCade,and my
Ikons binfulf andLiea �,� PANES Sf�D t,(�L
Lt¢ns Chs
Dale Contractor PTO 200ANUM,
ARCHITECTS DECLARATION 201-1000 AMPS
AZO I understand my plans shallbe used s public temmM
la. OVER IODOAPS - SQ.Fr.FLOOR AREA S/SQ.FT.
Q E Licensed Professional - SIGNSELECTRICAL
G y♦v
<y OWNER-BUILDER DECLARATION /, I CC
In SPECIAL CIRCUIT/MISC ��2 V�.
t. ! owingraRn.(Scatlameaemptfroossa Contractor's License Law fort he
>- following reason.6octlon 7011.5,Bushes and Professions Code:Any sty it S
O M H TEMP.METER OR POLE INST.
F� � county rryukesaperrtJt to site, demolish,
1 < ary.tructure peter to its Lsarance,atn requi¢s lheappli¢nt fornch permit to POWER DEVICES
CFO file a sued statement that he,is licensed pursuant to the provisions of the
Contractor's Lkeeme Law
Y S � geon hDivi. SWIMMING POOL ELECTRIC slon3o(theBusfnendPru/emlomCocer 9 orthahbesth mpttemfmnd n VALUATION
Q
applicant
lican for the alleged exemption. Any violation of Schon not re mo any OUTLETS-SWITCHES
appl¢ndred delta. subjects thupppcant tea civil penalty dna momtlun
g flue hundred dollen(fS00j.
R NEW RESIDENTIAL ELECTR kLF STORIES TYPECON'STRUCT10N'
j ❑I,as owner of the property,d e.employees with wages r there dale - _ I
G/-< sale compension,
will Buttro the ess and rk,andthestmcture Is not Intended e:TheC .tractr'oroff Law
d for ras
D vie(Sec 7011,Business and Pro(esloro Code:The Contractoh Llame law
S docs not apply to an owner of property who builds or improves themon,and Rp011 RFS.UNITS
who doesauchworkhimsel(orth.%hh0aown employees,provided that such — �K•
Improvements am not Intended oroffered forsale.If,however,thebullding or TOTAL:
Improvement bold within.neyear.fmmpletion,the owner-W ilderwillhave �y
t rden of proving that he did not Wild or improve for purpose ofsale.). QTY. PLUMBING PERn7If�TE
APN
Lj L a owner.(the property,am.7N4,Busivelyness
cons and
ingPro with ns Codd PE RM17ISSUANCE
contractors to conswathe pro)M(Sec.7044,Bus and Pro(esloru Code:
The Contvctor's License Law does not apply to an owner of property who ALTER-DRAIN 4 VENT-WATER(EN
Wilds or improves thereon, and who contracts fee such pWo cts with a FEE SUMMARY
co,Rlpa; W
or = m
licensed pursuant to the Contrar's License Law. BACK FLOW PROTECT.DEVICE
I III m exempt under Sec. B ak P C for this mann
DRAINS FLOOR ROOF,AREA,CON). SANITARY Y_ N_
Owner Date AELFRrf g
WONIOdAN COMPENSATION DECLARATION
111
PER TRAP SCI100L TAX Y_ N_
111 hereby affirm that I have a certificate of consent m self-insure,or RECFR'C a
¢ I.bC3800,0D,lab
J S o(Worken'Compewtlw lnsuran¢orr certified cmpytM1aarof Uec. GAEA.SYSTEM-1 INC PARR FIT Y OUTLETS —
N
Pollry N DING DI N
GAS FA.SYSTEM-OVER 4(FA)
Com BUILDING DIVISION FEES '
RCertified copy is M1e¢bytume city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
ray certified copy b filed with the city inspection division.]� CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID SSD
COMPENSATION INSURANCE gEWFRSANIT'ARY STOILM EA."Fr. RCOeI INN s
(Thlaanllon need n¢W completed lithe permit b forooe Funded dollar
a10))oefeaa.) WATER HEATTRW/VFNT/E.ECTR ENERGY FEE Y N
I certify that In the performun¢of the work forwhkh this permit 1•heed,
I shall not employ any person in any manner an w to become subject to the WATER SYSTEM/TREATING
Workeri Compenslton Laws of Calif¢nh. Date PAID
z Z Applicant NEW RFSIDFN'RAL PCMB. SQF7. Dale RCLCI HI
Z O NOTICETO APPLICANT:If ter makingthh Cenifloleof minion,you
Hshould becomembFct to the Workers-Compensation provelonso(the Labor TOTAL:
W jN Code,you most forthwith comply wilhsuch provisions rthis perMt•hall be I BUILDING FE
deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
ll o I hereby affirm that them bamnsmumon lending agency for the perform. ELECTRIC FEE
7 Z
an"
of the work for which this perMt is issued&c.3097,Civ.C.) TOTAL:
V O Lenders Name_ t i n PLUMBING FEE
LL ~ LtidersAcidre 1' QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O w I artilythat l have mad thhapplatl and statethat the above information
barren.I.gmttocomply with all atyand county ordinances and mate laws PERMIT ISSUANCE FEES AI /
y N rtlmiegtobuilding constmetion,ardbesby,.6c mreprexmaives fthb
(— = city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. Dale Reeei tp
- V a We)agreet• save,Icomand expenses
harmles the City of Cupertino P
8a judgment, penses which may In anyway scams AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City in conaequence of the granting of pe'�t AIRHANDLINGUNIT(OVEt10,D00CFM) CONSTRUCTIONTAX /
Signam CfAp\ia��traetor,h / \al Etc\ FxHAusr HooD(W/DUCT) CO^IN T CTION T
HAlARDOUS MA .RIALS DISGLOSU E r 1Y7 ate
Will the applicant or forum building occupant store or handle hmrdous HFATINGUNTTC170101), DBTU) Date Recel t✓w
nuterial as defined by the Cupertino Municipal Code,Chapter 9.12,and the p
HQ Yes'd s,lety Cade,SeNo
N.
a❑ on 25S32(a)7 - HEATING UNIT(OVER 100,OfA BTU) TOTAL: 'S
Will theappint future Wilding occupant use equipment oedevim VPN'DLATIONFAN(SINGLERESID) I DATE
which emit harardous air mntamtrant1a•defined by the Bay Area Air .
`• Quality Management District? BOILER-COMPOILPOR100,0009711) E13
Ycs ❑No iab c Q
havaread the huallousma requlata
menunder ER Chapter6.95 of BOILER-COMP 100,000 BTU) / 1a7 1
the Califomh health 6 Safety Code,Sctlons 25505,25533 and 25534.1 1
understand that lithe building doca not currently have a tenant,that it Is my NEW RESIDENTIALMECH. SQ.FT.
responsibility to rattly the occupant of the requirements which most be met MYI�Nf"-. --♦
priortoisuanoo ofaCerti(icateof Ocmpanry.
C caA ,I LIti,
Owner or au�rlud agent Vate ISSUED BY
TOTAL:
OFFICE COPY