21967 APPLICANT Tit) FILL IN INFORMATION WITHIN RED LINES — US E BALL POINT PEN ONLY
e
BuilQin at Identification rlIR ITNO.
21967 jtuiWing Addrea: �• '
Ii�o ei��nWle� Pl
nern ams: one: , APPUCKTIMMM=DATE
, ,.A, c;.,�I, CITY OF CUPERTIN6BUILDING DIVISION
cont d .N lie.Na: APPLICATION I PERMIT t
F-4
'� •r•� dvc r((LLLfi cavo p Z BUILDINGELECTMCALPLUMBING-MECHAMCAl CATEGORY CONTROLM
Architect/Engineer. Lk.N.
•� QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrea:3710 y'yLNVZI -Drs S, PERMITISSUANCE I�
LICENSED CONTRACTOR'S DECLARATION pPI7.[ANCESRES[DENCfAL L�F OB DESCRE'110N
I hereby affirm that l am licensed under provisions ofChapter9(commenI
ingwith Sedlon7f10O)of Dlvisi=3ofthe BudreaandPmfndonsCode,and my PANELS ,�•
Ilceme is n fuR f and died. 10'�� 'L `_
1C
LlcenseC LILYI IF TO 2DO ANTS
//ww'' N lig( l aa.
Date Contractor_
ARCHITECTS DECLARATION OVERVER30 AMTS1000 AMPS `�Fr.FLOOR AREA S/SQ.Fr.
M 0 O 1 understand my pita abaI be used m pubbc record. O
Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
io„ [hereby affirm that l am exempt from the Contradoes License Law for the
ZO 2 following mason.(Section 7031.5,Business and Profeaicns Code:Any city or TEMP.MEIPR ORPOLE INST.
P s' countywhichrequimaper twmmtmMaler,impm de=bshormpalr
`ay any strudure prior to its Issuance,also requires the Applicant for such permit to (OWER DEVICES
M file a signed statement that he L licensed pursuant to the provleloa of the _
Contradors License Law(Chapter 9(commencing with Section 7000)of Devi- SWI14VING POOL ELECTRIC ,VALUATIQOLa
111......E+0 i,nl,flh,Buslnms and PmfealonsCoddmthat he Is,", 11erefromand O O//
e?O the basis for the alleged eumption. Any WJ.fu m of Section 7031.5 by any OUTkT55V/TICHES}7KITJItE4 r D -
[GWCS] applicant fora permit subject the applicant to a dvil penalty of not nnrc than
R live hundred dollan(S.SOW. NEW RESIDENTIAL ELECTR SQFT. SIO ES' —TWE CONSTRIKT[ON
❑I,as owner of the property,or my employees with wages a their Bole
Z compensation,will do the work and the structure is not Intended or offered for
to CO sale&c,70K Busi.and Prefeni Code:The Commdors License Law
FS does not apply to an owner of property who build@ or Improves thereon,and OCC.GROUP RES.UN[rS
RES-
who does such work himself or through his own employees,provided that such
improvement@ arc not intended or offered for sale.If,however,the building or TOTAL:
improvement Is sold within oneyearofcompldbn,the owner-bu0derwill have
thP.ILurden of proving that he did not build or improve for purpose of Bale.). QTY. PLUMBING PERMIT FEE FLOOOZONE APN
LJ L a owner of the property,am exclusively mntrading with licensed PERMITISSUANCE
contractors to construct the project(Sec.7044,Business and Pro(ealoro Code:
The Contractor'.License Law don nor apply to an owner of property who ALTER-DRAIN Is VENT-WATER(EN
Wilda or Improves thaeee, and who contreda for such p(ujeds with a FEE SUMMARY
c ct )h...d pursuant to the Cormictes License Law., BACK FLOWFROTECT.DEVICE
OUTSIDE thLb
LJ I am exempt under Sec B k P C for this reason
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N_
Owner Date � RFiCEBPTN
WORKMAN COMPENSATION DECLARATION FNTIIRES.PER TRAP SCI IDOL TAX Y_ N
C31 hereby affirm that 1 have a cerdficate of consent to self-insure,or a RECEIPT a
rmnifini,m Worken'Campmufi.Insurance ora mrti(hd copy thereof*;K. GAS,EA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N-
3800,Lab C.) RECEIPT 0
PWIry M GAS.EA.SYSTEMAVER 4(EA) BUILDING DIVISION FEES
Co���qqqpppany
�Certllled copythercby furnished. GREASEANDUSTRLWASTRIN'I'ERcrPTOx PLANCHECK FEE
Certified copy le filed with the city Wpectian dlWston.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER.SANITARY-STORM F.A.20OFp, Date Recel t#
(rhlssMion need not be completed lithe permit is foron,hundred dollars ENERGY FEE Y N
(510()or lm.) WATER FiFATER W/VENT/FI.ECTR —
I certifythat N the performance of the work forwhich this permit Is Issued,
1 shall not employ eny person in any nner so as co 0W cd t9 the WATIBt SYSTEM/TREATING PAID
Worken'Corr tion Lwe o(Calif las Date �7(�1
O Z Appllmnl NEW RESIDENTIAL PLMB._SQX. Date Re xi t#
Z O NY3TICETOM ICANT:R,after makingthis CertBlamof Exempfioryyau TOTAL:
ahwldbecomes bjed to the Workers'Compereatiun prove, o(ehe Labor
N Code,you must forthwith comply with such provisions orthb permit shall be BUILDING O
W9 deemed cooked.CONSTRUCTION LENDING AGENCYSEISMIC FE a
CL 1herebyaffirtnthet there is a construction lendlngagenry for the Perform TOTAL: ELECTRIC FEE
M Z ante of the work for which this permit b Issued(vec.3097,Civ.CJ PLUMBING FEE
U O lender's Name
U. H Lenders Addrea QTY. - MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imrt.Iagrlhecompl withalationdcuntyodiance,selnforteIa. FEFt$IIt�II�' 'r
bconact.Iagreelo complywith andtyandcauntyordinanmand stsotwa PERMIT ISSUANCE r/ �jL
O• relatl tobuildingcomtrodioryand dproprtyauthorize in rcprnenpurposofthb —(--Da
} W cit tenterupon the above-mentioned property for W ion purposes. ALTER OR ADDTO MECH.
~ ? y(We)agreo ave,IndemNfy an d P (harmless the ity of Cu pertlno Date ReCel t#
1) against Babllhies,Ndgment,costsaede see whichmaym.Ayweyamuc AIR HA NDLING UNIT(TO 10,000 CFM) SUBTOTAL: 2fi,I II
Baleen d by m mnsequenrc�he ming edthis pemdt CONSTRUCTION TAX
N. AIR HANDLING UNIT(OVER 10,000 CFM)
^K CONSTRUCTION TAX PAID:
Bigmtu tAppllcent/Contndor Date
EXFIAUS'r HOOD(W/DUCT)
- HAZA R DOUS MATERIALS DISCLOSURE
Willlh applicant or future building occupant store or handle hazardous HEATING UNIT(TO lOD,0008TN Date RCCei (#
material as defined by the Cupertino MuNdpal Cade,Chapter 9.1Z and the 9
I ealth and Safety Cade Section 25532 W 7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yrs o equi VFN'TLATION FAN(SINGLE REBID) ISSUANCE DATE
W0Ithe xppllonior�nbuilding ompantusethe Bay A ar devices paw
whichemithazardouulr contaminant ane defined by the Bay Area AU BOILER-COMP OHP OR 100,000 BTU) P�11Q
W Illy Management District?
n❑Ya F-rg° BOILER-COMP(OVER 100,000 BTU)
I have read the bazaRr us materials requirements under Chapter 5.95 of i�
the Callomla Health h Safety Code,Sections 75505,25533 and 25534.7 APR
R (qi ss Wi
understand that if the building dm not currently have a tenant,that it is my NEW RESIDENTIAL MECH. - SQFT
responsibility to notify the occupant of the requirements which mi.tbemet �1j�aa jjtgkks����.►,ss�aas��
prior to Issuance of a Certificate of Occu perry. t��TI. NRV.
Ownerorauthorlud agent Date TOTAL: ISSUED BY: r �'
OFFICE COPY