21357 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pre'ect Identification I PERMIT NO,
WIZ13yo et/�Q 0 E7 1_)J �E e-�� �z- 21357
mer. ante:
nnC 77 CITY OF CUPERTINO-BUILDING DIVISION
conlnctora Name: APPLICATION I PERMIT ��Z�90
BUILDING-ELECIRICALPLUMBING-MECHAMCAL CATEGORY CONTROL Y
ArchltM/Engineer. Llc.No: '
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG UUZI PLUMB MLLn
�•
Add. C PERNaTISSUANCE �Z, ❑ ❑ ❑
LICENSEDCONTRACTOR'S DE LARATION -
Iherebya/Firm that Ism licensed underprovbimso(Chapter9(commam APP11ANCES-RESIDENTIAL JOB DESCRIPTION
-
IngwilhSenion7000)af Divblon3ofthe Bualmssand feuimsCode,andmy
limese is in fug forte ay�d effect. PANELS
LI«nx Claes LU Lk.Y �Od
Date/O_Z ConMaRor t4Eof-n v
_ UP TO 2DO ANTS
ARCHITECT'S DECLARATION 3111.1000 AMPS
0Nz0I understa nd my plans shall be used as co
public records OVER 1000 AMPS SQ.FT.FLDOR AREA S/SQ.FT.
��yj Licensed Professional SIGNSELECI...CA
�6
OWNER-BUILDER DECLARATION SpECULCBiCNT/ TSCep
L., 3, Ihereby affirm thatI am exempt the Contractors License Law fee the
7 oo O following mum.(Session MIS,Business and Professions Code:An n r Y a /
FZ county which requlrnapermit tomesimct,alter,Improve,demolish,or city
TEMP.METER OR POLE
[NBT.
anystrocture prior tolls Issuance,also requlresthe applicant for ouch permoto POWER DEVICES j•L A
r file a signed statement that he b licensed pursuant to the provisions of the �� _
3 u,yy Contractor's License Law(Clupler9(mmmencing with Section 7000)of Owl. SW IAIhENG POOL ELECITOC�� f VALUATION
p0J sine3ofthe1hdnessand ProfesstoesCode)orthat he b exempttherefromand Prs,_ -
•77 the basis for the alleged exemption. Any violation of Section 7MI5 7y any
<
applicant for a permit subjectsthe applicant to a civil Family of not more than UTLETBSWTICF6sFT7('IpQtFs a
fiv6undred dollars(¢500). \I r NEW RERDEMIAL ECTR rr en
I,as owner o!the property,or my employees with wages heli sal - SIOWES TYPE CONSTRUCTION
7a compensation,wllldothe work.and thestruchom b not intende0orolfere�-d in
O oak(See 7064,Busiwa tad Protamines Code:The Cantractore LiI mane taw
5� does not apply to an owner of pmpertywho but da or Improves i��eereoo,and OCC.CROUP RFS.UNITS
whodoumch workhlmeeQmlhrwgh Nsownemplayees,provld'Jdthatsuch
Improvements are not Intended oroflered foresk.I/,hawevep thi ulldlegor TOTAL 00
Improvement beold Mthlnomyearofcmnpl&t ktMo ner-bugderwNhave
thtImurden of proving that M did not build or improve/or purpose ofsale.).,;jM. PLUMBING PERMIT FEE
LJ L as owner of the property,am exclusively contracting with II«nied FLOOD ZONE APN
PERMIT ISSUANCE
contractors to construct the project(Sm 7044,Business and Profembv Cgle,
The Contractors License law does not apply to an owner of propertyiwho ALTER-DRAIN AVENTWATER(EA)
Wilds or improves themen, and who contracts for such ptojecb -wish's FEE SUMMARY
-qct{pct-o-W licensed pursuant to the Contractors License Law, BACK FLOW PROTECT.DEVICELJ I am exempt under Sec. B k P C for this reason OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
Owner Date RECEIPT Y
rffl�m
W011111AN COMPENSATION DECLARATION FDCrURESPER 7RAP SD{OOLTAK Y_ N_6 a'Ho thaIhveaxarr«'e ofmnxntoself-InRECEg'F Y
of oriser/C_jxuu'lonlmuranmorecertlledic.py thereo((Sec. GAS EA.SYSTEt-1 INC.40IIILEI5 PARKFEE Y NbCORF9F8TN GAS. ER 4(EA)ESYSTEM-OVEJ?aR BUILDING DI VISION FEES
Confined copy is hereby furnished. GREASE/WDUSIRL WASTE IJ!'FdRCEP'IDA PLANCHECKFEE
1 erllfiedeopykflledwithlhedtylmpection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRA)' PAIDZgq/Z, Q 17 l
COMPENSATION INSURANCE -'
CChiaxctbnneed not becompleted Blhepermit isformehundrd edollars SEWER-sANITARy.smRM EA.2isin Date Remi t#
($1000mleu.) WATER HEATER W/VENT/ELLCTR ENERGY FEE Y N
I mMfy that In the performance olthework forwhich lMa perry t is issued,
I shall not employ any person In any manner so as to become subject to the WATER SYSTE.t/TREATING
Workers Compenution Lawsof Callfomb.Date PAID
—
Z Z Applicant NEW RERDENMLI'LMB. SQ.Ff. Dale Remi t#
Z O NOTICETO APPLICANT.It,after making that Certifcste of Exemption,you
should berme subject to the Worker'Compensation provisbw of the Labor TOTAL:
N Code,you mu at forthwith comply with such provisions orthb permit shall be
W G deamed revoked. BUILDING FEE
C CONSTRUCTION LENDING AGENCY SEISMIC FEE
Iherebyafflrmthat there b a commuction lending agency for the perform, TOTAL: ELECTRIC FEE / Q
Z an«oflheworkforwhkhthbperMtlaL ed(See3097,C1v.C.)
Lenders Name - - PLUMBING FEE
LLF Lender'sAddroaa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O L/3• 0
W bmIeatifythatl havereadthb application and dm
atethattheabovetefoutlon
IL rrect.I agree to comply with all city and countyordlnaa«s.oddatelaws PERMIT ISSUANCE �.2- FEES PAID:
>. N relating to Wilding construction,and hereby authorise representative of this
city to enter upon the abo mens red property for Inspection purposes. ALTER OR ADDTO MECH.
Z (We)agr to Indemn cad keeph Men the City upertlno Date Re:ei t#
V against les,' d cats, and nen kh ryay lee ayamrue AIR HANDLING UNIT CEO 10,000 CFM) SUBTOTAL'
ago I n nanque « t grant) of permit AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
�� CONSTRUCTION TAX PAID:
Sig reo(Appg«cal/Contractor ate IXHAUST HOOD(W/DUC7)
HAZARDOUS MATERIALS DISCLOS E a/
Will the applicant or future building occopaet store or'§dish andous HEATING UNIT(TO 100,000 BTU) /. Date ReCel t#
material as defined by the Cupertino MuNdpal Code,Chapter cad the c
Health and Safety Cod Ion 35533(a)7 HEATING UNIT(OVER 100,000 B'IU) TOTAL: •y�j
❑Yea
Wlllthe applicantfuture Wild ing ocxvp.ot use equipment or devices VENTILATION FAN(SINGLE REM) ISSE0JydATE
whichroutMa.gem-ntsa Ltimt? mnle as defined by the Bay Area Air
1aYN
Quality Mt ham rd u air 7 BOILER-COMP D}E'GR 100,000 BTU)
IT Yes o p I BOILER-COMP(OVER100,0(0BTU) OCT 199E
ve read lheh out matenabre rerre under Chapter 6,95 of
the California Health k Safety Code,Sent m 7S 75533 and 3:534.I ,
wsderdandth fifth ulldingdo not reently ave a tenant,that It b my NEW RESIDENTIAL MECH. SQ.FT.
P. ili on theacco of erequl rrwWawhichmustbemet Eallar tat(au .1.�
prl o me aCertificat O pan !FN'V Vl b �1U
O.vnr ramhanzed agent to 5 ISSUED BY:� e_ a7'vr/GGr
TOTAL: J
OFFICE COPY