21406 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 21406
CITY OF CUPERTINO-BUILDING DIVISION Z _ Z5 —
Contnm
ci.e.Nae: Lie.N.: APPLICATION / PERMIT ! 1
CVf)eeTrNO f°1_yNl�( A BU(LDING-ELECTRICALPLUMBMGMPLHAMCAL CATEGORY CONTROL
ArclMflteR/Engine'er. Lk. o:
QTY ELECTRIC PERMIT FEE BUILDINGPERMITINFO
AAA""
Pezo -ad PERMITISSUANCE El E] ❑
LICENSE CONTRACTOR'S ECLARATI N
l hereby affirm that l am licensed under provisions of Chapter 9(commeea APPLIANCES-RFSIDENTIAL JOB DESCRUMON
Ing Mth Seation70W)of Divlslon3 ofthe Buslnessand ProlenionsCode,and my v
license Is In hull(arae and effect. PANELS
Llcense Clzm Llc tl c-O -Zs"_
Date V`!Cord meter 1
ARRCHITECPSDECLARATION 201-1000 AMPS 4G
Orel lunderstand eryplaresshallbeused aspublicrecords OVERIODOAMP5 SQ.FT.FLOORAREA $/SQ.Fr.
PqqP++ O
Licensed Professional SIGNSELECTRICAL
�6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
herebyaffi m that lamexempt from the Conlmool.License Law for the
O
following reasom
n.(Semon 7031S,Business and Profession,Code:Any city or' TEMP.METER OR POLE(NST.
countywhich rcqulreaa permlttomrutrun,alter,Unpmve,dennitsh,orrepalr
g any,tructure peorto its issuance,also requlmtheapplicaN for such permit to POWER DEVICES
li O Ole a signed statement that he b licensed pursuant to the provisions of the
3 w0 Conlradorb License Law(Chapter 9(rommencleg with Section 7000)of Divi- SWIMMING POOL ELECTRIC
,Ion 3ofthe Business and ProfemlonsCode)arthat he it esem therefromand VALUATION
the bash for the alleged exemption. Any violation of Section 70715 by any OUTLE7SSWITCHESFTXIURES
applicant for.perent sub)eab the applicant to a civil penalty of not more than
E �G five 1,as ownerofthepd dollars ro NEW RESIDENTIAL ELECTR SQ.Fr. STORIES TYPE CONSTRUCTION
I,as owner ll the property,or he employees with wages act their sale
e7a en 'orlon,wllldotheworkandthestmcturebnm Intended or offered for
$a ❑ sale(See 7014,Badnessand Pmfmskva Code:The Conmactols Liam,Law
d.mnotapplyloes owner of property who Wilds miceprove,thereon,and OCC.GROUP RFS.UNITS
pw, who domsuch work hlmaelforthraugh his own employees,provided that such
Improve=nU are nm Intended oraffered for vale.I(however,the building or TOTAL:
improvemanlfasold Mthlnoneyearofmmple iogtheowner-bulMerwillhave
ttijZurden of proving that he did not build or improve for purpose of ask,). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with Ilcen PFAMTT L`SSUANCE ;I p
rontractan to construct the project(Sm 7044,Business ami ProfeseIt"s e: N
e
The Contractor's License law don net apply to an owner m proper"onsty ho ALTER-DRAIN&VENT-WATEO(EA)
Wilds or Improves thereon,and who oantracis for such pnofecia wit a
cgp(factor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECI. ,. FEE SUMMARY
L,J I am exempt under Sec B &P C for this re n
RAINS FLOOR ROOF,-A N_�
Owner Date SANITARY Y_RF-CETT M
ss�� WORK MAN COMP ENSATcit DECLARATION r FIXNRF_S-PER TRAP �s�a SCIiMLTAX Y_ N_
L2!11 hereby a(((rse that I have•artl0ais of consent to self-inwrc,or — Gr W RECEIPT tl
ce 10aleofWOIwWCmoP..tkm lmunna or.certlfkd copythereof(Ree. GAS EA.SYSTEM-]INCA OUTLETS
PARK FEE Y N
00,Lbc.)
Policy tl CAS EA.SYSTEM-OVER 0(RA) RECEPT M
C m any B UILDING DI VIS ION FE ES
MCertlflcd copy is herebyth the city
CREASE/INDUSML WASTE INTERCEPTOR PLANCHECIC FEE
�Certlfled ropy V filed with the ctly Inspection dlvlelon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP URA
IPAID
COMPENSATIONNSNCE SEWER-SANITARY-STLIRM EA.2"T, Date RCCCI tfF
Qhiseecilon need not be completedSpermitURA le(Erna,hundred dollen
($100)orless.) WATER HEATER W/VENT/EI.FOTR ENERGYFEE Y N
I certify that In the performance of the work for which this permit is Issued, —
I aha 11 not employ any person In any manner not set to become subject to the WATER SYSITM/TRFATINC
Workery Compensation laws.!California. Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SOFT. Date Rett'i tlf
Z O NOTICE TO APPLICANT.I,after making l his Certificate of Evemptlon,you
should become subject to the Workers'Compensation provisions o(Ihe Lebon TOTAL:
fn Code,you must forthwith comply with such provisions orthl,permit shall be U N
W > dnmed revoked. ,
ll C FEE
C CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hemby.f0rm that there V a romWctlon lending agency for the perform- ELECTRIC FEE
TOTAL:
Lc dof ar' Nwark(orwhlch this parmlt I.issued(Sec.3097,CIv.C.) pe
LL Le.der'.Address PLUMBING FEE Gl,g1
14, L) lenders Addrees QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertifythatlhave read lhisappBcatlonand state that theabave informaaon
M mooned.l agree to comply with all city and rountyordlnances and state laws PERMITLSSUANCE' PEES PAID:
} latingto Wilding construction,and hereby authomm representatives ofth4
H 2 city to enter upon the abovcmentioned property for Inspection Purposes. ALTER OR ADD TO MECH. Date Re[ei tN'
_ Mr)agree to save,Indemnify an d keep harmless the City of Cu pert Inca P
against liabilities,judgments,costs and expenses which may In any way accrue AIR HANDLING UNIT(T010,000 CFM) SUBTOTAL:
ago lost said City In consequence of the seaming of this permit.
S a� AIR HANDLING UNIT(OVER 10,000 CIM) CONSTRUCTION TAX
�GCCfi/C
Slgvdfuie (Applicant/Contranor Dale • EXHAUB'f HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZA R DOES MATERIALS DISCLOSURE
Wllltheapplimst or/uturc building occupant store or hand In haxardous ((EATING UNIT(TO 100,000 BIIn
materia l as defined by the Cupertino Mu nicipal Code,Chaptcr 9.12,and the _ Date Receipt# ��,�aaT3�yEarss
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: Ur,2 c'V
❑ Yes NO
Will the applicant or tore building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hamdous air tests entrants as defined by the Bay Area Air
Quality Management BOILER{DMP slrict7 DHP OR 100,000 BTU)
Yet, No
have read lhehaza esus matedaLs requlremenh underChaplcr 6.95 of BORER-COMP(OVQR 100,00)BTU) 1���
the Glifemla Ilealth&Safety Code,Sections 25505,25533 and 25534.I P
understand that lithe building doe,net mreently have a tenant,that it l9 my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which must be mel
prior 10 issuance of a Certificate of Occupancy. FEA
to
Owner or aulharlmd gen Date TOTAL: ISSUED BY f R
r_
OFFICE COPY