21724 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification I,O-, j -) -�) PERMIT NO.
Building Address:
21724
A A
� REGO�r Gr�Uu� CITY OF CUPERTINO-BUILDING DIVISION
contra mr.N,m[: / p LIc.No: APPLICATION / PERMIT 1 Z— t1 \
• " E(S C.� !% �Gv/ - ) BUILDING-FEF MCAL-PLUMBING-MECIIAMCAL CATEGORY CONIROLX
Arehlt.d/Engineer: Llc.No:
i]// �✓ N BUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE
naaras,: rFRhar7s5unNCE jv ® 13
LICENI F.D CONTRAROR'S DECLARATION Vl L�
Ih[rebyaffirm lhatlam ll«nud underprovhloneof CM1a)st[r9(mmmeno- APPLIANCFSRESIDENITAL 21
JOB DFSCRI'TION
ingwlth Section 7000).HAvbloxi .!Rise Busin(nand P.fe..fonsCesio andmy,
limnse Is In full fo and ES
died. PAN
Lt..Chs Li.N Y~L /
Date Contractor
ARCHITECTS DECLARATION 201-1000 AM
qw�y O I understsrad my porn shall he used sa public records )
j
FT.FLOOR AREA $/SQ.Fr.
lJ Fj Licensed I'micsumal SIGNS ELECW;Lu Ivi P ILf LTqC:
<� OWNER-BUILDER DECLARATION E IA'CIRC L— 33
I hembyaNrm that l am exempt from the Contractors License law for the
0 A-•y murity g reason.(Section 7¢115,Rusines and Pufesloro Code:Any dty or
P,,t v' TEMP. OR(POLE IN
P.�a1 cvuntywhtne print tna permlttommrequires th .ptove,demoWh,ortompair _
Ym 6 any swcture tatementahsuanae,lice sed pursuant t the provisor ions
ofpermit e POWER DEVICES
C�� fie a signed statement that k h licensed pursuant to the provbiov of Rise
�u Contractor's License OeLaw(Chapter 9(co mericingwith Section 7000)of Divi-n SWIMMING POOL ELECTRIC
ion3of the Busiesand Rdmbro Cade)orthat h<b soon tFemfcomand VALUATION
,�`�<5 the ksic for the alleged exemption. Any viclatin of Section 7MI.S by any OU7FLETS-SWITCHFSF7X7URFS / p
❑ appBcantf.n permit sobje 4stheapplicanttoa rnil penalty.frau rmmtHn / a
five hundred dollars SM. NEW RESIDENTIAL ELECIR /
1,as owner of the roc SQ.FT. STORIES '17fPECONSTERUCTTON
property,sty,or my Employees with wages sa their sole
�7a mmpensation,will do to&c. 0KB.,luithe wmKand the tlucturehnot
ontractor orofferedLaw
5�❑ vie(Sec.]OG,Bushes and Profesbm Code:ik Contractots Llarue law '
$ does not apply to an owner of property who builds or improves t hereon,and
a-s^ who doessuch work himself or through his own employees,provided that such OCC.GROUT' RFS.UNITS
Improvements are not intended oroffered forsale.I(however,thebuildlng or TOTAL:
improvement hsold withinoneyearotcompldWn,theowner-bullderwill have
me�urdenotpmvingth,t he dm QTy. PLUMBING PERMIT PEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with licensed
contract..to construct the project(Sec.7014,Bushes and I'mfessbm Cade: PERMIT ISSUANCE
The Contractor's License Law don not apply to an owner of property who ,tib-DRAW k VENT-WATER(FA)
builds or Improve thereon,and who contracts for such pRojeas with a FEE SUMMARY
co„BBII.laaor(s)licensed pursuant to the Contractor's Liense Law. BAIX FLOW PROTECT.DEVICEL�I am exempt under Sec. B k P C for this reason OUTSIDE FFES
DRAINS FTGOK ROOF,AREA,GOND. SANITARY Y_ N_
Owner Date RECEIPT
WOHIQ.IAN COMPENSATION DECLARATION
❑T hereby affirm that I have a Eectifinm pIX.NftErc PER IERAIP SCHOOLTAX Y_ N_
te,of consent to self-Insure, a RECF]I NX
mrttflcate-IWorkeri Compensation]vunmes or a minified copy thereof(Sec. GAS F.I.SYSTEM-1 INCA OI171EI5 PARK FFR Y_ N
Poll38M,lab CJ RECEIPT N
Collq X GAS EA.SYSTEM-OVER 4(EA)
Cansa r-••Y40 laC-x tlUILDINC DI VISION FEES
�Certltled copy is herebytd. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
QCertUed copy h filed withh the the dsty inspection division. ,
CERTIHCA11 OF E(EMPTION FROM WORKERS' GREASE TRAP PAID -
v c
COMPENSATION INSURANCE SE4EI45AMI•ARY-SNRM G 3IXIF1. Date Recei tM/S. d
(This stolon need not be completed if the permit h ferone hundred dollars
(St0f1)mlaae.) ENERGY FEE Y N_
Imrtitythat In the performance of thework forwhich this permit is hued, WATFRHEITERW/VENT/ELFCTR —
1 shall not employ any person In any manner n as to become subject to the WATER SYSTEM/TRGTING
Workers'Compensation Laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.Fr. Date Remi tit
Z O NOTICE T'O APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers Compensation provbloru of the Labor TOTAL:
N Code,you mu at forthwith comply with such provisions or this pcmNtshall be ��
W j deemed rooked. BUILDING •F •s
CL c CONSTRUCr10N LENDING AGENCY SEISMIC FEE ,
1 hereby affirm that there Is a construction lending agency for the perform ELECTRIC FEE
7 Z an of the work for which this permit Isis Ed(Sec.3097,Civ.C.) TOTAL: Q,
U O Landers Name�X/� - PLUMBING FEE
LL I— Lender's Addresa /-/ - QEY. MECHANICAL PERMIT FEE MECHANICAL FEE p
O W �mrtifythatl have read this app' tion and satethat the above information .
restlagreetocomplywlthailcityand countyordmancesand statelaws PERMIT ISSUANCE FEES PAID:
} N relating to building construction,and hereby authorise copresentatives ofthh -�I L�C.1_ / o
F = city to enter upon the above-mentioned ove- entioned property for Inspection purposes. ALTFRORADDTOMECH. Date _!f ^rRreael til
_ (We)agree to save,indemni/y an d keep harmless the City of Cupertino P
ag,Inst llabilltln,pdgm,itts,.0...d expenses which may In any wsyacome AIR HA NDLING?rUNIT(17010,000 CFM) SUBTOTAL:
agaot said City In con,equ ensu of the granting of this permit.
AIR HA NDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX ..S^
C /_ 2 — q/ CO ST UCTION TAX PAID:
Signature of Ap mZARD US Date IXHAlJST HOOD(W/DUCT) 4l
HAZARDOUS MATER LS DISCLOSURE _l _
Will the applicant or future building occupant store or handle hanrdous HEATING UNIT CFO He,”BTU) Dye Receipt#
material as defined by the Cupertino Municipal Code,Chapter 9.1;and the -
Health and Safety Code Sedion 2S532(a)? HEATING UNIT(OVER 100,"BTU) TOTAL: ..O-
❑Yn M No I
@� NCEp
Will theapplicanN
t or building occupant use equipment or devices VEDIATION FAN(SINGLE RF_SID) IS ,ATE
which Emit hasardom it costs minants.,defined by the Bay Area Mr
Qua lily Ma rugocnP t District? BOILER-COMP 0M OR IOQOW RTI)
Ycs ❑No
Ile
Ihavemreadthehu,NousmaterialsrequlmmentsunderChapter6.95of BDILER-COMP(OVER IW,OWBTU) �gll�1 1
the California Health k SafetyCode,Sectbns 25505,25533 and 25534.I
understand that lithe bulldlngdoes not currently have a tenant,that it is my NEW RFSIDFMIAL FIECH. SQ.R
resporuibility to nctily the occupant of the requirements which must be met
Price to issuance a.Certifies of Occupancy. A.'�'M y
_�C /_Zc!'/— LGc L"
gv.eror nut66 imd.gErt Date ,SS se r
TOTAL:
OFFICE COPY