21675 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldin Pro'et Identification PERMITN'O.
'' Building Address: 21675
r SS 4't &/ornA- 10".
nens, ams. one: A A A
rrjlc j ria �i a 2S - 0 p CITY OF CUPERTINO-BUILDING DIVISION
Contractors Name: LIc.No: APPLICATION /PERMIT ���
Wf •BIRLDINGE.ECITtICALPLUMBING-MLCI-IAMCAL CATEGORY CONTROL p
/- Aahltet/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE - BUILDING PERMIT INFO
Address: - Ian -x Li � ❑ 1:1PERMITISSUANCE ICV
LICENSED CONTRACTOR'S DECLARATION
lhereby afon mthat laiv licensed!underBusi essa dPro Chapter9(Commenc APPLIANCESRESIDEN77AL JOB DFSCRI']ION
(ngweM1 in
ofd effeon3 ofthe Businessand ProfesslonsCodeend my
license is In fol force and effect. PANELS
License ClastLk.# FWV\a
Data Centimeter
ARCHITECPS DECLARATION 201-1000 AMT'S
�2 I understand my plansshal be used as publiceecords. OVERIODOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
a dCO SIGNS ELECTRICAL
(9 Licensed Pr fessiowl
<Q� OWNER-BUILDER DECLARATION t SPECIAL Cll2CNT/MI5C
E„�?7 Iherebyri irmthal l am exempt from the Contractor's License Law for the _
Zp P_n'� following reason.(Sectlon 7071.5,Business and Professions Code:Any city or
02.1-� roomy which requires a permit to construct,alter,irnprove,demolish,or repairVPOWER
I'ER OR POLE INST.
F`ui�Csi any structure prior to Its issuance,also requires the applicant for such permit to
" file a signed statement that he St licensed pursuant to the provisions of theEVICES
Contractor's License Law(Chapter9 frommenctng with Section 7000)of DWI- G POOL ELECTRIC
sion3 ofthe Business and ProfessionsCode)orthat he b exem therefromand VALUATION
the basis for the alleged exemption. Any violation of Section 7071.5 by anySWITCHES-FIXTURES
applicant fora permit subjectathe applicant to a civil penalty of not more thanrve ndreddollen(i+(XB. DENDAL ELECIR ES TYPECONSTRUCTION
�n as owner of the property,or my employees with wages as their sale
mpensatlon,will do the work,and the structure is not intended or offered for
le(Sac.7044,Business and Professions Code:The Contractors License Law
S S does not apply to an owner of property who builds or Improves thereon,and a GROUP - RES.UNITSwhodocssuchwork himself orthrough hisownemployees,provided thatsuch
pl improvements are not Intended oroffered for sale.I(however,thebuiiding or TOTAL:
improvement usold within omyearofcomplation,the owner-bu ilderwill have
t Tenoten of proving that he did nbuild or Improve for purpose of sale.). Qry. PLUMBING PERMIT FEE
L1,as..or of the property,am exclusively mntrating with Ilceneed NE APN
contncton to Construct the project(Sec.7044,Business a nd Professions Code: PERMIT ISSUANCE
The Contractors License law does not apply to an..at of property who
bulli.or Improves thereon,and who contras for such plojets with a ALTER-DRAIN&VENT-WATER(EN
co,_nt.Tactors)Scared pursuant to the Contnnor:License Law. BACK FLAW PROTECT.DEVICE FEE SUMMARY
Lf I am exempt under Sec.. B &P C for this mason
\
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N OUTSIDE FEES
Owner - Date JIM=#
WORKMAN COMPENSATION DECLARATION FD(TURES PER TRAP SCHOOLTAX Y_ N
1 1-11 hereby affirm that I have a artlBcate of consent to self-Inwre,or RECET If
\� reAtfiuteof Workers Compere tionlrumnmoramrtlfiedmpythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N_
3800,lab C.) RECEIPT#
Pettey#
GAE .SYSTEM-OVER d(EA)
BUI LDING DI VIS ION FEES
ertiBed
Copy b hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCI'IECK FEE
F-1 Certified mpy is filed with the city Inspection division.
CERTIFICATE OF IXEMPFION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.700FT.`
(This section need not be completed If the permit Is for one hundred dollars . DatC RCceit#
($100)orless.) WATER HEATER w/vEHT/F1.ECTx ENERGY FEE Y_ N_
1 renRy that 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 WATER SYSTE.T/TREATING
Worken'Comperation Laws of California Date - PAID
O Z Applicant - NEWRESIDENTIALPLIAH. SQFT. Date Recei t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you''
rshould become subject to the Workers''Compensrtion provisions of the Labor TOTAL:
N Code,you=at forthwith comply with such provbions orthis permit shall be
BUILDING FEE
lJl > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Ihereby affirm that there Lsaconstruction lending agency for the perform TOTAL: ELECTRIC FEE
Z once of the work for which this Permit is becued(Sec.3097,Civ.C.)
02 Landers Name PLUMBING FEE
H Lenders Address QTY. MECHANICAL PERMIT FEE
LL MECHANICAL FEE
U Irenifytharee to comply
uth aBatlonandunte that
ordinances
rdina cess and hif.re
laws FEES PAID:
Q W Emrngt. builds g comply tion all ndlgandcounty oc reprresand eesoftsys PERMIT ISSUANCE,
} N citytogmbupongconsuutiontioned rcbyrtyor in rcpresenpurpoof this
F cityNenter
gee to the,indemnify an
property for inspection purposes. ALTE(Oft ADDTO MECH.
? (We)agree to save,indemnify an d keep harMess the City of Cupertino Date ReCCipt#
V against llabilitks,judgments,costsand expenses which may in anyw.ys.c AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL:
against d C' to ron eu t e granting of this parrot.
AIRHANDENGUNTT(OVFRIO,(DOCFM) CONSTRUCTION TAX
CONSTRUCTION TAX PAID:
Signatureof Applio / ontractor Date IXHAUSTHOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haeardous HEATING UNIT(TO IOgODO BTU) Date Roaeipt#
material as dented by the Cupertino Municipal Code,Chapter 9.1 Z and the - -
Health and Safety Code Section 75537(x)? HEATING UNIT(OVER IM,00)BTU) TOTAL: &
❑ Yes M No
Will the applies rat or future building occupant use equi proem or dovices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit ham rdous air contamlr nls as defined by the Bay Area Air PM
Management District? BOILER-COMP OHP OR 100,000 BTU)
Yea1 1 No
Ihave rcadtheh QusmatenabrequirementsunderChapter6.95of BOILER-COMP(OVER 100,000 BTU) 51013
the California Health&Safety Code,Setior2550S,25533 and 75534. 1 JAN [rT
understand that if the building does not currentlyhave a tenanhthat It isrey NEW RFSIDENTIALMECH. SQ.FT'. ...
resor to ts..nonot Core cafe,o t ofOccupancy.
the requiramentswhich rwst be met app_El#6,,,an
pnorrolssuance ofaCcrti(iate o(Ompanry. I� �(�,�(�/�
Owner or authonad agent Date ISSUED BY Ex"'
TOTAL:
OFFICE COPY