21437 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro ed Identification PERMIT NO.,
Building Address: 21437
Owner a Nam, one:
_ CITY OF CUPERTINO-BUILDING DIVISION
on a 's Name: Lie.No:_ APPLICATION I PERMIT '" 7— �/
6�� BUILDINCELECTRICAL-PLUMBING-MECHANICAL CATEGORY CONTROL#
Arc ted/Engineer. Lie.No:
-� QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
A V r/✓II 3,2 W PERMITISSUANCE ��aM
LICENSED CONTRACTOR' ECLARATION El � Y—�
Iherebyafflrmthatlamhcenudunderproa•Lslonsof Chapter9(mmmene APPLIANCES-RESIDENTIAL JOB DESCRE'TION
In eine I.ection 70)0)of d doer.3 ofthe BuYmresand ProfesslonsCode,and my
ingwi SI.ection force,and died. ''// tt PANELS
Lke,.Clan Lie# D�YSJ^
Datef-- Contractor — 201 IO UPTOMAM
ARCHITECTS DECLARATION
q�q�vv rsO Zp I understand my plana shall be used me public records. OVER I OLIO 5/
AMPS SQ.FT.FLOOR AREA SQ.FT.
k U Licensed Professional SIGNSELECTRICAL
<6OWNER-BUILDER DECLARATION
In SPECIALCIRCUIT/MISC
Z s,�Pa Thereby afFlrm lNtlant exempt Contractor's License Law f¢the
following reason.(Eectlon 7031.5,Business and Professions Code:My city or
Ff'8 countywhich requimsa perouttomemrun,alter,Improve,demolish,orrepair TEMP.METER OR POLE INST.
q� '.� any Yructurepr rtoitsts..rcgaL+ requimtheappUmntforauchper tto POWER DEVICES
E5 file a signed statement the he Is Bmnsed punuut to the provisions of the
W6 Conlradora Lmmum SLaw(Cha er9(mmnrnein Ith Section 7000).f DIA- VALUATION OS aion3ofthe Businessand Profemion Code)urthtlhebexemptthercfromand 5'WB.SMING POOL ELECTRIC
Q the basis for the alleged exemption. Any violation of Section 7031.5 by any O[IfLEIS5W17CHFSFlXNRES
mppBmnt for a permit subjecuthe applicant to a civil penalty of no rnorethan
five hundred dollars UISM. SQ / STORIES TYPE CONSTRUCTION
rR NEW RESIDENTIAL ELECIR Ff.
�n ❑I,asowner l theproperty,ornd he employees r their
mmpeec.70 ,Buterm s iodhe Pe tagon ,[rodham Wended L offeredLev
doe(Sm.7apply
to
oanowner fpmpety Code:bulds Contactorsves theme Law
does noho ssuchtoan owner alpmpertywhonemplrimproovidedthat
and OCC.GROUP RES.UNITS
EE wprovemmis an n MmxEort orofferedugh ewne.If,lu ea,pmvidedilding or
improvementsarenmintended earofecoferule.I(, owever,lheerlldingyr TOTAL:
Improvement 4wldwilhinoneyearofcomplmioMlheowner-W Rderwlll have
t rdm of proving the he did out build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
L as owner of the property,am exclusively=trading with 11¢ se
nd FLOOD ZONE APN
mamn eloto construct the preject(Sm 70K Business and Profession Code: PERMIT ISSUANCE ,sI3
The Contractors Limue Law does net apply to an owner m property who ALTER-DRAIN&VERA-WATER MA) UVV
Wilds or improves thereon,and who contracts for such ptojeds with a FEE SUMMARY
contrador(s)B¢nsed pursuant to the Contractor's License Law, BACK FLOW PROTECT.DEVICE
01 am exempt under See. B&P C for this reason
Owner Dee DRAINS FLOOR ROOF,AREA,RIND. SANITARY Y_ N_
WORIOdAN COMPENSATION DECLARATION RECEBPf#
ereby affirm the I have a¢#Tints of consent to ill!-Imre,err a FDCnJRES PER TRAP SCHOOL TAA Y_ N_
rh
aRECEIT 0
GAS EA.SYSTEM-1 INC.4 OUTLETS PARK FEE Y N_
# GASFA.SYSTCM-OVER4(CA) RECEIPT#nv BUILDING DIVISION FEES
�CMIFled copy V hereby fumtshed.
�ertHied mpytsfRed wlN the city inspection divialon. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER.SANTrARY-STORM EA 200FT Date Recei t#
(TMseection need nor becompleted dthe permit ts f¢onehundred dollars
(SI00) len.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I¢mdythat in the pedorman¢ofehework for which this persalt I.Issued,
1 shag nm employ any person ts any manner n u to become wbjed io the WATER SYSIE)A/TREATING
Workers Cempenndoe laws of C.I fomia.Date PAI D
OZ Applinnt NEW RESIDENTIAL PLMB. SQ.ET. Date Remi t#
Z O NOTICE TO APPLICANT:11, 11m,making this Certdlcate of EaemPllus,you
FN should become subject m,be Werke.'Compensation Provblonsof the Labor TOTAL:
Code,you most forthwith comply with such provisions or this permit shall be_ BUILDING FEE
W j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC ITE
CL MO IherebyaffiorkNthethem tsaromtIsbuted&c. ,Civ.
perform TOTAL. D ELECTRIC FEE
0 Z Lender the work(or which this permit tsblued($ee.3097,Civ.CJ r
U O Lenders Na PLUMBING FEE /41/1049
LL 1- Leeder.Addmss QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imrtlfythatlhavemadthaappbmtionand Oatethatlheaboveinfor tiara
ca
1 Is rred.I agree to comply with all city and county ordinances and Yate laws PERMIT ISSUANCE FEES PAID:
m
W relating tubuildingnstructlon,and hereby autherbse representatives ofthls
F erty Z city to enter upon the above-mentioned propfor Impaction purposes. ALTER OR ADD TO MECH. Date ReCel t#
_ (We)agree to save,IndemNfy an d keep harmless the City of Cu pedino
against liabilities,judgments,roes and expenses which may In say way accrue AIR HANDLING UNIT ITO I O,ODO CFM) SUBTOTAL:
against u d City in consequence of the granting of this permit. -
1 AIR HANDLING UNIT(OVER ISWOCFM) CONSTRUCTION TAX
Signature of Applicar,117Contractor Ixte IXHAUS'r Howfiv/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfutom building occupant store or handle hazardous BEATING UNIT(TO 100,000 SM Date Rixel t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and SafetyC ton 25532(a)7 - HEATING UNIT(OVER 100,000 BTU) TOTAL: r
❑ Ye. o
W[lithe dpplimnt or core building occupant use equipment or devices VENTILATION FAN(SINGLE RE5ID) IS ATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management I BOILER-COMP(3TD'OR 100,0(0 BTU)
11��Yea No y 6
- `)•have read the hazy oils material,req.1mmentsunder Chapter 6.95 of BOILER.COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sections 25'505,25533 and 25534. I '•" 1
understand that If the building don not mrrently have,tenant that it Is my NEW RESIDENTIAL MECH. SQ.IT. -
responsibility to notify the occupant of the requirements which must be met ,
priorloissuanceof Certdkate of Occupancy.
2r i /—9-
9/
suer or authorlud ageV Date
TOTAL: ISSUED BY:
OFFICE COPY