21288 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification - - PERMIT NO.
Building Address: -
�z ► 000 Sr Cte 21288
caner. one: - A
area• CITY OF CUPERTINO-BUILDING DIVISION ! I7.� Q •.
contractor's GSy Lic�p� APPLICATION /PERMIT
% BUILDINC-ELECTMCALPLUMBINC MECHAMCAL CATEGORY CONTROL`2 ,Q
Mme
rc tett/ neer: Me.No: lD 1�J
�L' / Qi'Y" t SBL. 1 " ,PE I' , , I'CE,,, .,BUILDING PERMIT INFO
Add.. /1/ - PERMITISSUANCE
LICENSED CONTRACTOR'S ECLARATION - � -.
I hereby affirm that lam hcemed under provkdomof Chapter 9(commade. APPLIANCES-RESIDENTIAL - JOB DESCRB'TION
Ingwlth Sacdon7000)of DIW 0tar3ofthe Buslnessand ProfessionsCode,and my
Ilcensels(nfuH and d'em'o PANELS .�(••`�
_ Lloense lass Lle.p 1
Date Contractor '. r
AACHITE DECLARATION 201-1000AMP5
mO Zp Iunderetand my plan shall bn and
u publicrcmrda. -S OVERIOOOAMP§ SQ.F7.FLOORAREA $/90.17.
�l[y,�, Licensed Professional - SIGNS ELECTRICAL
,„ "" Gi �R
6 Wy OWNER-BUILDER DECLARATION SPECIALCIRCUIT/M `
I hxmbyafflrm that l..exempt from the Contractor's License law for the ESE
f - ,
2�5' following reason.(Scabs 7031.5,Buslnem and Professions Code:Any city or
�"'u9 ntywhich requlreaa permit nm
o construct,alter,Improve,demolish,orrepair TEMP.METER OR ILE[NST.
Pm1 N any structure prior to its bwance,also requires the applicant for such perMt t° (OWER DEVICES
P G•�� file a signed statement that he b licensed pursuant to the provbloru of the -
SOSContractors License Law(Chapter 9(commencing with Section 70D3)of Divi-
slon3°fthe Business and Prefeesioru Code)orthat hats exempt therefromand SWIMMING FOOL CfRIC VALUATION
the basis for the alleged exemption. Any violation of Section 70113 by any ^ UTILETSSWITC FIXTURES ' l 3,3 00
applicantforapedrutwh)ectatheapptica .f
nt too civil penalty more than `
five hundred delta.($500). 11
�j I as owner of the pre",or employees with wa esastheirsole NEWRESIDENcompen7IA ELGCTR SQ.IT. OI21ES 'IYI'E CON51'12UCf10
Q•^�n ❑• P othe orka Yerne°Y B
'C 6 d for
sale&c.7044,
s7044,willdese.ad rRaousid.Cda:Thnd thestructum no[Intendedol.oaa Law -
5 O sale(gee appy to alnow owner
f property who
Wilds C improves Llcerua law '
[j$$ docs nonsucht apply toan.wnel of property his one employees,Fred,
OCC.CR IIP RES.UNITS
C. whodoeseuch work himself or hleownemployees,provided that such
Improyementaarenotintendedoroffered formic.ILhowever,thchulldingor TOTAL: t a
Improvement lssotd wilhinoneyearofcomplMlon,the owner-bullderwlll have
the,urden of proving that he did not bund or improve for purpose of sale.). QTY, '•it��"'PLUM BINE PERMIT-, }• }'FEE '' DwNE ' APN
u L as owner of the property,am exclusively mord—ng with tlunsed PERMIT ISSUANCE
contractors to construct the project(Sec.7W4v Business and Professions Code: . .
The Contractor's License Law does net apply to an owner of property who ALTER-DRAIN&VEIJT-WATER(EA)
builds or Impioves thereon,and who contracts for such pgojeM with a R FEE SUMMARY`
on tjactods)Bceneed pursumt to the Contractor's License Law. BACK FLOW PROTECT.DEVICE ",
LJ I am exempt under Set B &P C for this reason
Owner Data
DRAINS ET.00R ROOP.ARCA,GOND.• SANITARY Y N- ,
RECEBe7 Y
WOR KMAN COMPENSATION DECLARATION FIXTURES PER TR" SCHOOLTAX Y N
F11 hereby affirm that I have a'cerlificate of consent to sel6lnsurs,ora RECEIPT
car fusteof Workma'C°mpemation hums..or a unified copy thereof(Sec. . GAS EA.SYSTEM-1 P1C.40[JILETS PARK FPR Y N
3500,Lab C.) ..
RECER'T N
Polity N CAS EA.SYSTEM-0VER 4(EA)
Co���mPPPany - BUILDING DIVISION Fiif:S
cofied copy b hereby furnished. CREASEIINDUS[k WASTE INTERCEPTOR PLANCHECK PEE
rimed copy breed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' iGREASETRAP pAIDj(h-11L Sst •'�X�s
COMPENSATION INSURANCESEWER-SANITARY-SIURM EA.ZOOFT. Date RCC21 t# aC'1L
(fhb section need rid be completed If the perMt bt for one hundred dollars
(5100).rlcse.) WATER HEATER w/vFxr/EI.ECTR ENERGY FEE . Y N -
I certify that In the performance of the work forwhlch this permit b Issued, —
1 shall not employ any person in any manner an ae to become subject to the .,�F�p.o [7]% I
Workers'Compensation laws of California.Date WATER SYSTEM/TREATING PAIDN 1"' Lfgs
C' Z' Applicant - NEWRFSIDENTIALPLMB. SQ.HT, DB[e RCtt'1- t# I.Z X
Z O NOTICE TO APPLICANT:U,aBer making this Certificate.(Exemption,you
should become subject to the Worker.Compematlon provisions of the Labor TOTAL: qqqt-ql
CCN Code,you must forthwith comply with web provisions orthis permlt shall be DUIING FEE eZ3
W mre
> deeed voked. - —L
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a 1herebyaffirm that mems a construction lending agency for the perform -
.7 Z' anm of the work for which this permit b Issued(Sec.309x,Civ.C.) TOTAL: ELECTRIC FEE
U O Lander.Name - PLUMBING FEE
LL I- tenders Address - QTY. MECHANICAL PERMIT' " FGE+'I MECHANICAL FEE
OW Icnrtifythat l havereadthisapplicanonand statethat the she Information - _
t11 emrr .lagreetocomplywithalldtyandrountyordlnanm,vednatelaws PERMIT ISSUANCE ICT FEES PAID:
} relating to building construction,and hereby authorize representatives ofthb
E— N city to enter upon the above-mentioned property for lnspectionpurposes. ALTER OR ADD TO MECH. gxQ7
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino - Date Receipt#
•V against li Illtics,judg nt.,cost.antl ex ngqeea whkhmayin.aymyxcerus AIR HANDLING UNIT(TO 10,"CFM) SUBTOTAL:
rynce
agal t d I co sueofth anI gof this pemu'y - -
i / AIR HANDLING UNIT(OVER IQODOCEM) CONSTRUCTION TAX
g 011 ant/Contractorate EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID: '
HAZARDOUS MATERIALS DISCL SURE
1 heappHranI or future building°aU)
vpant store or handle hazardous HEATING UNIT 103,000 BTBTU) RCCCI f#
dial as defined by the Cupertino Municipal Cotle,Chapter 9,12,and the - - ,
Health and SafetyCode Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes ,ix!No
Will the applicant ortutum building occupant use equipment or devices VENTILATION PAN(SINGLE RFSID) P°haC' AI qCE DA'L'E
which emt harardousatr contaminants as defined by the Bay Area Air to a"e,�✓ .
Quality Management District? BOILER-COMP QHP OR 100,0W BTU)
Yas No JAN
�[,,11E Q
Thave rcadthe h QousmaterialsrequirementsunderChapter6.95of BOILER-COMP(OVER 100,000BTU) .1 n �GY'
the California Health&Safety Code,Sections 25505,25533 and 25534.1
i understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. � -
mponsibility to notify the occupant of the requirements which must be mot - 0
prior to issuance of a Certificate°!Occupancy. ) -
Owner or authorized agent - 'Date - 199UED BY: �'
TOTAL:
OFFICE COPY.