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21644 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Holding Project Identification - PlUtMITNO.
Building Address: 21644
203 5 STuvE s C
WMr• me. an•:
( CITY OF CUPERTINO-BUILDING DIVISION
Contradzao��rm
s Nae: I a. a: APPLICATION / PERMIT
V � .F BUILDING-E.BCTRICAI.PLUMBINGMECHANICAL CATEGORY CONT%*3N
A stat/Englnrer. L .Na: (D 770
Q'IY ELECTRIC PERMIT �FE�E/� BUILDING PERMIT INFO
^ ress' PERMITISSUANCE yam/
LICF.NSF.D CONTRALTO DECLARATION
I hereby affirm that l am licensed under provisions ofChapter9(commm APPLIANCES-RESIDENTIAL JOB DESCRIPTION
In ease is ectlon force of d effeon3otthe8uslneuand Professions Cade,and my �`�
lice..bin full force and d(ea PANELS xa % '
Lirense Claes Lic.p V
Data Contractor
ARCHITECTS DECLARATION 201-1030 AMPS
077 I understand my plana shall be used as public records. OVER1000AMPS 55.FT.FLOOR AREA ems$/e.Q.FT.
k� Licensed Professorial SIGNSELECTRICAL
<6 OWNER-BUILDER DECLARATION
rn SI'ECIALCItCUIT/MISC
owing rasormlhatlat7emmpt(romthe Contractor's License law fort he
qqqqqq
Followingeason.fSecticat tt mmtmaandpro@aloneeo le h,ymyor
s' rountywhlN mrylresa permittoanstruct,alter improve,dertnllsh,ormpalr TEMPI METER 0RPOLE INST.
any structure prior to its Issuance,a Lao requires the applicant for such permit to POWER DEVICES
file a signed statement that he It licensed pursuant to the provident,of the
O o. Contndors License Law(Chapter 9(commencing with S km 7000)of Dlvi-
L�O�n SWIMMING POOL ELECTRIC
� the basis for the
alleged
dexemption. Any)orthat violation f exempt therefrom and VALUATION
g ❑ the Wab for the•listed eectsth ap Any violation o/Secpenalty
o not m by any OUTLETSSwITC FS r-]_ ©
o appBesntfora permit subjects the applicant toe dull pevlty erns morcthan J
five hundred dollars($500). NEWREiIc DENTIA SQ.FT. STORIES 7YPE CONSIRLCTION
�n ❑1,as owner of the property,or my employees with wages as their sale
compeneatlon,willdolhe work,and theammo re isnot Intended or offemd far
Osale(Sa.7044,Buamess and Pmfeulots Code:The Contractors Darted Law
$$
does net apply to an owner a property who builds or improves thereon,and OCC.GROUP RFS.UNITS
who does such work him.Iforthrough his own employees,provided that such
improvements am not intended proffered for sale.If,however thebullding or T TA
improvement is sold within ormyearofcomplmion,the owner-bullderwlll have
ttiurden ofpmving that he did no[bulld orlmprove(a purpose ofbaleJ. QTY, IN IT FEE FT.oDD ZD ArN
U 4 as owner of the property,am exclusively contracting with licensed
wntrcd..t..retrodthep.jed(See70KBuaffim.MP,&.s .Code: ( PERM ^ ��
The Contractor's Lia..law does net apply to an owner of property,who ��g-DRAIN& ATER(EA)
builds or Improved thereon,and who contracts for such p(ojects with a
.t.[ador(e)Ilan.d pursuant tothe Contractor's Llc,n.Law. BA FLOW PROTIL FEE SUMMARY
LU I am exempt under Sec B k P C for this mason
DRAINS FLOOR ROOF,AREA,CO SANITARY Y N
Owner Date - gp�pRep p
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP Lt.do SCI{OOL TAX Y_ N
Ut hereby affirm that I have o lmurane of consent d self-there,ora lKL R��.N
re00,Iaeof Warken'Compersatlonlnsurana ora rertlfd ropythemo((Sec. GAS EA.SYSTEM-1 INC.40I1TL PARK FFR Y N
360q lab C.)
Policy p GAS EA.SYSTEM-OVER 4(FA) DING DI N
Cany BUILIDVISION FEES
am
any
copy is,hereby te
❑Certified espy b filed withh the city
ivpedlan division. GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECICFEE
ty
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID ��
COMPENSATION INSURANCE SEWER-SANITARY-STORM RC
EA.200ET. Date CCI t# IJ-0 03
(Ihb section teatime be completed If the permit b forone hundred dollars
(51Mmiess.) 1 WATER HEATER W/VEM/ELECTR ��a ENERGY FEE Y N
Icertifythat In the performance of the work forwhich this Permit is issued, �y
I shall not employ any person In any manner so as to become subject to the
Workers'Comp,nsatlonlaws of California.Date WATER SY51l➢rt/rREAnNc PAID
0Z Applicant - NEW RESIDENTIAL PLMB. SQFL .Date Recei t#
Z Z NOTICE 70 APPLICANT:If,after naming this Certi(late o(Exemptlan,you _
should beam,subject to the Worknre'Compersat cel provisions o(the Labor TOTAL:
CC W Code,you=at forthwith comply with such provisions orthb perrvlt shall be BUILDING 'E
y deemed revoked.
LU
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
Iha.bysM.that there b a mwtructlon lending agency for the perform- TOTAL: e�o.a ELECTRIC FEE
7 Z aha of the work for which this permit b Issued(Bee.3097,Civ.C.) W
0 O Tender.Name PLUMBING FEE
LL N Lceder.Addreaa Q'IY. MECHANICALPERMIT FEE MECHANICAL FEE
OW I certify thatl have mad this applkatianand statethattheabove lnfoms0on L
IL bmrrect.I dgree to comply with all city and county ordinances and date laws t PERMIT ISSUANCE FEES PAID:
). relating to building ecnstructlon,and hereby authorize representatives of this �•/�
F Z city to enter upon the above�mentlor d property for inspection purposes. It ALTER OR ADD TO MECH. �w Date ReCel t#
Z (We)agree to save,Indemnify an d keep harmien the City of Cu pertme, P
against Ilitles,judpmngta,aysbandeapen.s whlchmaylnanywayaceme AIR HANDLING UNIT(TO 10,Ol10 CFM) SUBTOTAL'
,gal ea In • the gra.ting ofthlspermlt. -
CJ_
AIR HANDUNGUNIT(OVER Io,0o0CFM) CONSTRUCTION TAX
Signature of Applleset/Contrador Data EXHAUST HOOD(W/DUC'D CONSTRUCTION TAX PAID:
HAZARDOUS MATER LS UI SCIASURE
Will the applies at or future building oaupant stare or handle hazardous HEATING UNIT(TO 100,000 BTU)
mDate Receipt#
awrial as defined by the Cupertino Municipal Code,Chapter 9.1$and the .
Heahhand Safely Code Be ion 25532(P)7 HEATING UNIT(OVER 00,000 BTU) TOTAL: —
❑ Yea Ndo
Will the applicant or future building occupant use equipment ordevices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit hamrdousair mataMnantsas defined bythe Bay Area Air S '(pry
Quality Management Dletd BOILER-COMP DE EP OR IDLOW 8TU)
ETI Yea o .�ahl
have read the bozo cuematerials requirements under Chapter 6.95 of BOUXIE-COMP(OVER 100,0008TU) Ifau
the understand
that
lith building Safety Code, of cu rr 25505,ve a t and 25534. I
uadertandthat llheaccupadoes nota currently awhich noustitlsmy NEW RESIDENTIAL MECH. SQ.I7.
responsibility to notify the oaupant of the requlrerrenls which must be and
Arlo Lesuance ora�erti(late ofOmpanry. "Alto
�nSsQ
Owner or auinruo,i agent ' Data
TOTAL: ISSUED 8Y:
OFFICE COPY