21680 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildln project Identification PERMIT NO. .
Building
uWing Add.:
21680rcr. . oAPPUCA IION SUBMITTAL DAM
G(Jo Q ti T Cm X14 1 [ L` CITY OF CUPERTINO-BUILDING DIVISION
co tray«/ APPLICATION /PERMIT
E-_7T2 Z / BUTLDING-ELECMCA4PLUMBING-MFiCHANICAL CATEGORY CONTROL R
A chhea/Englruer: LIc No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add. I'ERh9"C]56UANE ❑ 1:11I a
LICENSED CONTRACTORS DECLARATION �J
IMrebyal.70that lam Bcemed Me,M=3ofheBuM ovbbruoffeWp r9(ammrn APPLIANCES-RESIDENTIAL BD RErT10N
Ing wlth5ecdan7000)ofpdsion3o(lens Busircusnd Prolessiasu Code,and my
1=limnsebin / defies.^a� PANFTS
g Cb k I�..0�S 71-'1 5�
nract.r,L,4a4 UP TO 2DOAMPS
CHITECFS DECLARATION 12M.1000 AMPS
µµ77Z I understood my plarcsluHbe used w publicrecorda OVFRIODOAMPS SQ.FT.FLOOR AREA S/SQ.FT.
y�j. Licurned Pmfembnal SIGNS ELECTRICAL
6 OWNER-BUILDER DECLARATION SL'CCULCIRCUIT/ML'S.
7 F' G IhertbyafOnntlutlaro exempt(romthe Contrenor'sLbva Law fm tM
p folbwirig rtucn.(Seaton 70115,BuaInm sod Profmbru Code:My city or
TEMP.MLTFIt OR POLE]NST.
P��� munlywhkh rayuWapermNtomrolrua,aker,improve,demolleh,orrtµlr .
fianye =mprlortolblm c,aborequlmtheappbmntfmsudpe to POWER DEVICES
PS rd S file a signed mttrorm that In b Ikcnxd Purauanl to the pmWbns of me
PWj Oq Contractor's Lkrmr Law(Chapter 9(mmmencing with Sect1on 7000)of DIW- SWIMMINGPOOLELECIRIC
E,30 slon3ofthe Businmand ProfmWmCMe)orthehebexemptthemfromeM VALUATION
Othe basis for the alleged exemption. Any violation of Section 7m15 by any OUTLETS-SWITCHES-FIXTURES-SWITCHES-FIXTURESECSC appU..t fora persub)n[ notm s the applicant to.civil penalty a nmore than
0� five hundred dolL.($500). NEW RF9DFNIIAI,Fi ttT4 FI.
.- ❑ rc
I,as avr of the Property,or my employees with wages as their sok STORIFB TYPE CONSTRUCTION
compensation,will do the work rob ro
and the sttlure t Intended or offered for
5 a sok(5,170KBuelrcu aod Profmbru Code:The Cmuraaora Ll.L w
(j�$ dm not apply to an owner of property who builds or improves thereonand OCC.GROUP RIS UNITS
EE who doe'such work hMselfor through his own employeea,Provided that such
Improvemeaa am sol Intrnded oroHertd(a.ak.IL however,the W INIng a TOTAL:
improvement beold whhinomrarofcompinbn,theowner-WIlden have
H ($den of proving that he did not baud or improve for purpose ofea)e.). QTY. PLUMBING PERMIT FEE
Ll L as avner of the pmperty,am exclusively oxraW
Acg with lammed
FLOOD ZONE APN
contractors to comtma the project(See 7011,Brulnm and Pmfmlom Code: PERMIT'ISSUANCE pyx
The Contractor'•Lkerm law don rwl apply to an owner a property who W
hall" or Improve thereon, and who contracts for such proem with• ALTER-DRAW 4 VENT-WATER(FA)
qlatI+ctm(a)Hennaed Pursuant to the Conrad«.Lune Law. BAac FLOW PROTECT.DEVICE FEE SUMMARY
"I am exempt under Sec B k P C for then recon
DRAINS FLOOR ROOF,AREA,ODND. SANITARY Y_ N_
Owner Date RIxpPTa
❑1 here
A
WORKMN COMPENSATION DECLARATION
FIXNRFS PER TRAP SCHOOLTAX Y N
by affirm that I have a mrtl0cam of consent to self-Uwre,or a REG=
cemflateof Wmlo,riComPenrtlon l...oramaified copythereof(Sec. GAS FA.SYSTEM-1 WC1 OUTLETS PARK FEE Y N
RFCEIIT#
lJ GAS]A.SYSTEM-OVER 4(FA)
Cam ray_ nil-- � BUILDING DIVISION FEES .,
�CenlRed copy b l,d with
the c d. GREASE/INDUSTRL WASTE INTERCIP'IDR PLANCHECK FEE
❑CenNed ropy b filed with lM city Im)sMbn dMslm.
CERTIFICATE OF EXEMPTION FROM WORKERS GRFJSETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.XQFi. Date Recd tN
(1"hbeeabn need na be<omplaed H the permit b fmorc hundrM dollen
($100)orythad in WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
lar ed employ
an person
mannerhe so as to b Wspermicbbo the
1 ahaH not employ any peon in any miner at aa to become Rnb}M to the WATIRSYS Eh[/TREATING -
Worken'Compenwbnlawso(Gllfornh. Date PAID
-
z Z NOplicant TL ETO APPLICANT:]/,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQET. Date Recei IM
O should become aub),ct to the Workeri Cumperudbn pnovhbru of the labor , `y�...���J �'(���, TOTAL:
cc Code,yaimudforthwlth.p)y Wthsuchpmvbbeuorthbperm .Elbe t ,li-Vp-T"\r/�� `/Y✓�� Id.Cs'
LU � deemed revoked.
BUILDING FEE
LU — CONSTRUCTION LENDING AGENCY 5EISMIC FEE
a Iherebyafnrrothatthembamrotrualm kodingagency lortM penamm TOTAL ELECTRIC FEE
Z and oflhew rkforwhlchthbpemdtbbe C3ec3097,CN.C.)
U O I<Mer'.Name PLUMBING FEE
LL
Uml&.Addresa - QTY. MECHANICAL PERMIT FEE
L) I certify MECHANICAL FEE
O W oo,c.fthaihave plyh itppHcay.nd eUtet. l above Information
brorr t building
camPlywlth and1wrrbyauth repoese tat Wtelawe PERMITISSUANCE FEES PAID:
} N rtytingto Wilaintromvm bn,aM pnyauNorberep npurp of this
cu CIVOagnect. ,e,tndenandfbrcd luopeharml Wh.CffofCppm. ALTFRORADD TO MIAs.
Z (WJ agrre to ave,IodemNfy an a keep harMm the Ory or Cupertino Date Reeelptq
V agaWtllabWtke,�udgmmh,mdsaM expenx.which myln anywayamue AIR HANDLING UNR(TO10,ODOCFM) SUBTOTAL:
ago WtBala CNyInmnsryuena atM gnntIng athle petrnR. AIRHANDLING UNIT(OVER IO,OWCFW CONSTRUCTIONTAX
Slgnuturruf Appliant/Contractor Date EXHAUBTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WllltheappllcaM mfutum WBding coupon(xort orMMk ha,adoua HEATING UNIT(TO 100,000 BM Date ReceitN
materbl as defined by the Capealno Municipal Code,Chapter 9.1Z and the
II Ath and Sddy Cade Sect 1.25537(a)i HEATING UNIT(OVER IOD,ODO BTU) TOTAL:
❑ Yes No
Will the ipplicant ogtum building oaopant use equipment ordevim VENTILATION FAN(SINGLE REBID) ISSp7}[�i,pATE
which emit hamrdous ab contambarata a.deRrud by the Bay Area Air �`+�/'�yXL�i/l
Quality nawgement District?BOM ER-COMP OHP OR 100,0(10 BTU) a/H
• Ihave read the ha nous mater,als regWrtmenbunaer Clupterf 95 fir BORER-COMP(OVER 100,000 BTU) -IDLY 6 1 1
tI Ca H! blieahh&Safety Code,SMbtu 255 W,25533 and 25531.1
undo that If Wilding does rrently luv`t. enanLthatlthmy NEW RESIDENTIAL MECH. 9�FT
sea Hltyto not[ fit e=Lcnentawhkhnurthemct pr1[Tf/`f�jpy.W—
p ohauaae t W "'TSLaI�xEj'�Q��� ,,,,
Owner orathhoriaed agent Date ISSUEDB
TOTAL
OFFICE COPY