21489 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: zan � - 21489
t_nvIiers a - one: APPLICATION SURIMIAL DA IT
//o3 CITY OF CUPERTINO-BUILDING DIVISION
contrattnr's Name: 'u<.Nn: APPLICATION /PERMIT e [ U
_ BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL p
rc Rett/Engi er Lic.No:
QTY .ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address 5 - PEFMTISSUANCE D 06 rVI ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that l am Bcensed under provisions of Chapter 9(oureeni APPEANCESRESIDENTIAL ]OB DESCRB'TION
DateingwlthSccUmi7000)of Division3 ofthe Businessand Poefessi...Codeand \ ys• �,�'.a.
1elnfu/ B effect 4 PANELS / n '^.v,.a'L �
License Class Lie.# // �,(/
Dale/ G Contractor
ARCHITECTS DECLARATION 201-1000AMP9 IN
rc0 Z I understand my plans shall be used as public records. OVER 1000 SQ.Fr.FLOOR AREA $/SQ.FT.
pq± OSIGNS ELECTRICAL
�J�j Licensed Professional
6 m OWNER-BUILDER DECLARATION
In e/r SPFGLLL CIR T/ ;C
L., � owing ya ..(Bud[..701-5,Burm that I am exempt siness
Profaoh License Law firths
0z�:�Q following reason.(Sc Uan 7QilS,Bwlnesand Pmfevlve, Code:Any city or .METQt LEI
W county which requires a permit to construct,alter,impmve,demolbh,orrepair
C L'ui any structure prior to Its Issuance,also requires the applicant for such permit to DEVI
file a signed statement that he is licensed pursuant to the provisions of the _
31.: Contractor's License Law(Chapter-9(commencing with Section 7000)of Divi- . S t POOL RIC VALUATION
Ei sion
F3ofthe Businessand Profemlow Code)orthathelaexempttherefmmand �p rs
G the basis for the alleged exemption. Any violation of Section 70315 by any OUTLE SWI ,ys V (J
applicant for a permit subjects the applicant to a civil penalty of not more than l/ o 0 D
five hundred dollars($.508).
i,as owner of the RESIDLNTIA ELLC SQ.FT. 5TORf TYPECONSTRUCTION
7 Q, compensation, property,or employees with wages r thele sole
.Is&c.
0KBuiness work andthes Code; h not intended or offered for
5 O doe(Sec.7ply to anessandf property
who
builds or
or improves thereon,
Urerue Law
$ does not apply toanownerorthrou hhis o nem orimpmovided that and n (�
F.j^ as as
whodoessuchworkhimself orthrwgh hisownemployss,provided that such I (,�. OCC..Ct.. .I1N
improvements arena intended oroffered!orale.I(howevegthebuildingor TOTAL-
improvement issold within one year oficompletion,the owner-builderwillhave
the rdenafpnwlr,Uat rte did nm Wild arimmomf.,pur,ouv.fmIs.). QTY. PLUMBING.PERMIT ".-E . ' A
IW
Lj L as owner of the property,am exclusively contracting with Iictmd PERMITISSUANCE
contractors to construct the project(Sec 7064,Businessand professions Code: DAT
The Contractor's License Law does nor apply to an owner of property who
ALTER-DRAIN&VEN'T-WATER(EAI
bis0da or])prow thereon,and who contracts for such p ujem with.. a E SUMMI
c traaorexemtundernsed ant Sec.totheContractorsLicense Law. BALI(FLOW PROTECT.DEVICE
IR
❑I am exempt under Sec. a&'P C for this mason
Owner L., OUTSI DE FEES
Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTDRES PER TRAP SCHOOL LAX Y_ N_
❑1 hereby affirm that I have a certificate of consent to selfdnsure,or RECEIPT#
certificate ofWorkere Compematiml] ranceoracertified copythemo((Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE 'Y N
Pull,Lab C.) RF-C=p
Polity p GAS EA.SYSTEM-OVER 4(EA)
Com anv BUILDING DIVISION FEES
[�cenieed copy It hereby furnished. GREASEANDUSTRI WASTE INTERCEPTOR PLANC14ECK FEE
F1 Certified copy b filed with the city trop<um division. _
CERTIFICATE OF E(EM PTION FROM WORKERS' ' GREASE TRAP PAID 74IFF
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2(IDFT. DdIC ReOel t#
(rhos section need net be comIfpleted the permit Isfor one hundred dollars
($1M)or les.) WATER HEATER w/VENT/E.[CIR ENERGY FEE Y N
I certify that in the performance ofthe work forwhlch this permit is Issued,
I shall not employ any person In any manner so as to _ subject to the WATER SYSTEM/TREATING
wurken'C. airs La aofaII I Dat. 90 PAID )
O nppuant / a // �- Date Remi t#
Z - NEW RESIDENTIAL PLMB. SQ.PT. '
Z O Noncero L ANT: a er�ii a`kTBt�irs ekBlate or Exemption,roll .
should subject toJ eWorken'Comperwtlon provtsior,s ofthe Labor TOTAL:
¢ j Code.you=atfonhwit comply with such provisioroorthis permit shall be BUILDINGFEE .e0
W _ deemed revokes. ,
CONSTRUCTION LENDING AGENCY SEISMIC FEE
M z Ihereby affirenthatthem usacovuuctlonlending agency for the perform TorpL: ELECTRIC FEE -OQ
'O ance ofthe work for which this permit b issued(Sec.3097,Civ.Q -
(,) I..dere N.me PLUMBING FEE
H Lendera Adareaa QTY. MECHANICAL PERMIT FLE
O W Icekifythat i have read thisapplloE.
tl...nd stmethat the above Information MECHANICAL FE
IL is correct.l agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. relating to Wilding censtructlon,and hereby authodm representatives afthis
N city to enter upon the above-mentioned property for inspection purposes. ALTEtORADDTOMECH.
Z (We)agree to save,indemnify an a keep harmless the city of Cupertino Date Receipt#
V
against liabilities,}adgmens,c<atsand expenses which may inanywayaccme AIR HANDLING UNTrCID 10,"CFM) SUBTOTAL: U11-40 I
against said City in censequence of th granting of this permit
AIR HANDLING UNIT(OVFR 10,000CI:M). CONSTRUCTION TAX
Signature ofmC acme Date EXHAUST HOOD(co/DUCT) CONSTRUCTION TAX PAID:
HA OUo TRIALS DISCLOSURE -
Willthe plican rfuture building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#.
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the
Health and Safety CW e Sea'On 25532(a)2 HEATING UNIT(OVER=0(0 BTU) TOTAL:
❑t) LAN°
Wit)emit
appliantorrumrebuildong occupant use equipment or devices VENTILATION PAN(SINGLE REBID) ISSUANCE DATE
hklhemit M1aremira atrrict? ntsasdented by the Bay Area Air P�O
(�1u-tsoy Management District? BOILER-COMP OHP OR 100,0(10 BTU)
L� Yes F3JW
' ]havcread the haz,Musmaterials requirements under Cha pter6.95of� BOILER-COMP(OVER IW,OWBTU) �1J0� 2 O �g90
the California health&Safety Cade,Sectlore 25505,25533 and 25534. I
uruluoi d that if the building dim not currently have.tenant,that it is my NEWRESIDENTIALMECH. SQ.FT.
responsibility to notify the occupant of the requimments which must be met a�
prior til nce ofd Ccrtificitteof Occupancy. L� City elf ritnArfinq
Owner authori ag nt - Date ISSUED BY: *4'AZO
O �
.TOTAL: ��
OFFICE COPY