21646 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
ldln Project identification PRU:OT NO.
Building Address:
o70 Vali Green 1) r- . 21646
Com UTC( CITY OF CUPERTINO-BUILDING DIVISION Q
APPLICATION / PERMIT i — —q I
BUILDINGELECTMCAL PLUMBINGMECHANICAL CAT!Z CONTROL/
tchlt /Engineers sec N.
(� [[�� T� G Q . ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Addne+e�/—] C, Gvel n • PF30MTIS'UANCE �(� ❑ ❑
LICENSED CONTRACTORS DECLARATION
IHrebyelfiren that l.mlkcnn dunderpn WansofC pter9(mmrrRnc APPLIANCFSRESIDEMTAL
ingwlth5ecdon700D)of Divbion3ofmeBu. .rc dPmfesilon.Cadgand
Manx is in full force and effect PANELS .
uoerse ClausteLk..�t
Da $_1Conincior
C'• Q9_
ARCFFTECTSalibeus D.public
OVER
AMPS
µp��W20 IuMerstand my plans eHBbe used republic nemNa OVER IW0 AMPS SQ.FT.FLOOR AREA f/9].Fp.
E L Licensed Professional SIGNSELFL7RICAL
<<�< OWNER-BUILDER DECLARATION SPEICIALCIRCUIT/MLSC - -
pt, a ffl
I herebyarmthat l am exempt fromme Contnctofe Lkemehawfmthe
o fallowing mason.65sG1on 70315, s Busheand Pmfesbns Code:Any city or
OZ1..� TEMP.METER ORIOLE INST.
F� countywhkh rcqubnapemdHo mrmtrun,ilter,Mprove,drmoHh,ornepilr
anystmct prbctoltsfrwamc al reqs estheappBantfmwchpe to POWER DEVICES
g Rha a signed statement that he b limned pumrnnt to the provisions,of the
Oµ Contractor'.License Law(Chapter 9(commencing with Section 7000)of Divl-
O .b
S n3ofineBuilneseandPrf.s .CWe)orm.thei, amptmerefromard MNG ICIX,ELECTRC VALUATION
6 9 the Heb for the alleged exemption. Any vldatlon of Section 7MIS by any -�yyY1.rcH6f1XfIJRE5 Q
O a pph.tf.r.pemdt.bie theapp0canttoad ipemly4nat=mthan
Sc
Ileundred dolhrs(f500L NEW RESIDENTIAL UaC $Qpl'. STORES TYPECONSIRUCTION
I es owner of the property,or rey employees with wages as their sole
compersadon,willdothe,work and the structure is rd bderde i or offered for
Oule$ee 7DH,Builneeeaod Pro(eslons Code:The contractor.umme law
$ does neat apply to an owner of property who Wilda or Improves thereon,and
S^ OCC.GROUP RFS.I1N77'S
who doessuchwork hlmeelfmma
thrgh hl. wn employees,provided that such ,
Impovemenb are out Intended proffered f«ule.IC however,thebuildbg or AL L
Improvementbsoldwhhlnoneyearofcomplel theownerb.0dcrw01have
t"rdeno(provingthe hedfd rot Wild orimprow furpurposeofule.). QTy. PLUMBIN T FEE FIADD ZONE APN
LJ I,u owner of the property,am erchaWely comtracting with limned pQN1II ISSUANCE
contractors to mnswct the pmject(Sea 70M Beninese and Profe»bru Code.
Th,Common,'.Lbinee Lw don n«apply to an owner ofproperty who
build•or Improve thaeoR and who mrdnm f«such p,)ects with a AL -DRAA76 - ATER
cgattet«(.)limmanI panus.t to the Contractor'•Llmose law. BA WPRO D FEE SUMMARY
LJ I am exempt under Sec B A P C for this crepes
OUTSIDE FEES
• Omer Dee ECL
DRAT R PPF,AREA- UV SANITARY Y N_
WORKMAN COMPENSATION DECLARATION RIZ—IY
❑1 hrrtby,affirm the I have a certlflate of consent to self-town,«a SCI IOOI.TAX Y N
RECEB'f N
certificate of Workeri certified!Compensation Insurance orcertified!copy thereof free.
3800,Lab C.) GAS EA. -I INCIOUTLE75 PARK FEE Y. N
R RFS N
Poon a GAS G. .OVER4(G
Com - BUILDING DIVISION FEES
nulednspybherebyfursehed. GREASE/INDUSIRLW R PLANCHECKFEE
Certified copy b Bled with the city,inspection division.
CUTIFICAT'E OF E'(Elvi FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-res .Z(XIFT Date Recei t#
(Ihlesenbn need oat b completed Bthe pemde b f«one hundred do0an
(ft(D)mlese') ENERGY FEE Y N
Im"yethat lntheperfor uofthewcekforwWd W.pem ised, WATER HEATER W/VEM/FILCTR
1 shin not employ any penin In any manner o as to become subject to the
WATERSYSIVd/TRGnNc
w«ken; m
eopensatbn Lawsof GBfomuela.D � � PAID
0 Z Appllrao NEWRF9DENTIALPLMB. Date Recel t#
Z NDTICETOAPPLICAN'I':I(,aper making this Certificate of Eaemptbn,yw �'�'
y mould bemmeaubject to the W.rkeri Compensation provisions of the l.bar TOTAL
Cade,You none forthwith comply with such pmvlvlons or this permN.hall be
EE
W > deemvo
ed reked. '
a O CONSTRUCTION LENDING AGENCY SEISMICE
I nerety.mnn tb hat there le a construction lending agency ler the perform ELECTRIC FEE
Z ece Ithe workfor which this permit loved LSea 3097,CW.C.) TOTAL 1
02 Lender's Name PLUMBING FEE
1= Lender'.Address QTY. MECFIANICAL PERMIT FEE
O W l«dfythatl HvereadthbapplotbnaMd tethattheabovelnfonnutlon MECHANICAL FEE
M bconY
rr .Iagreeto comply with ail cityaM county ordWnas and atatelawn PERMIT ISSUANCE FEES PAID:
M relming to building conslr.ction,aM Hreby authwbi representatives of this
Z city to enter.Pon the above-mentioned property for Wpectbn purpo.n. ALTERORADDTOMFLH. Date Revel t#
V — (We)ague to saw,indemntfy an d keep hamdes the City of C.pertbm
against liabilities,I,dgmew,cotsind esp.which may many way a. AIR HANDLING UNIT(170 10,0110 CFM) SUBTOTAL:
ge nst said City In consequence of the grant log of this permit.
(/tAIR HANDLING UNIT(OVER l0,000CF.M) CONSTRUCTION TAX,
y q I
Sig�tvra ofApp0an g Date E%IIAl15T HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DI SCIE)SURE
Will the applloni or future building occupant stop or handle ha ardou• HEATING UNIT(70 100,0D0 BTU) ' Date Revel t#
material as de0wd by the Cupertlnn Municipal Cade,Chapter 9.1Z and the
Health and!
Y. Safety Code
Sectlo 75532W? HEATING UNIT(OVER 100,000 BTU) TOTAL:
Will theapplosen future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISjUp�Al(:I,.I3 TE'
which eMt haardous air contaminants as defined by the Bay Area An, '3��TiJI{Ci{I
Quality Meugemcnt D -0Us
District? BOMERDMP Of IF OR 100,OOD BT /T�k
Y. ❑❑No ISI y K `P�
I have mad the In vrdouematerials requirements under Chapter6.95of BO FR�MProVLI 100,000 BT �A'y
the C.lifomia Heahh k Safety Code,Sea lens 75505,75533 and 7553/.I
underaaM that if the building docs not currently have.tenant,that It Is:ny NEW RESIDENTIAL MECH. SQ.FT
rnponsmOBy to notify the occupa red of the requirements which must be met
prior to Isuane,of a Certificate of Occupancy. T
Owner or authorised agent _ Date TOTAL: ISUEDBY: N+O �•'�`�)
OFFICE COPY