21019 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 21019
VV�Y��✓� �e�3 CITY OF CUPERTINO-BUILDING DIVISION
coots nr'.Na : Lie."°: APPLICATION / PERMIT
BUILDING-MECTRICAI.PLUMBINC-MECHAMCAL CATEGORY CONTROL If
Arch Engineer. 110c,No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add— (I 137, ' T PERMITiSSUANCE � ❑ ❑ ❑
11 LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am am"under provlsions of Chapter 9(commenc APPLIANCES RESIDENTIAL TOB DESCRUMON
IngwlthSection7000)of DtWslon3 ofthe Buenessand Profen=$Code,and my
Lice ie Infu fJlopepndeltec< a 5 PANELS
Ltrenyp:Isss !Y LIeY I 7
DaleNllel Co srvcm r� UPT02DOANIPS Y
lI s(•'� ARCHITECPS DECLARATION - 201-1"AMS KL�w -
OZOC I understand my plane shag be used as public record. OVERIOOOAMPS SQ.FT.FLOORAR $/SQ.FT.
u Licensed Peofmalorul SIGNS ELECTRICAL
�6 OWNER-BUILDER DECLARATION SPECGLCIRCUI MLSC
ZFp, � Ihereby of rnthat l am exempt from the Contractors License Law for the
O Z F- following reason.(Section 7011.5,Business and Professions Code:Any city or P.MECQ9OR
nr,� county which requires a permit to construct,alter,Improve,demolish,or repair
enystmcture prior to Its Issuance,also requires the applicant for such permit to
O0k a signed statement the he Is licensed pursuant to the provIslom of the PAVkRDEVICES
�OI� Contractor's License Law(Chapter 9(commencing with Sea1on7000)ofDivi-
s1mn3ofthe Busineuand ProfessbmuC°de)orthathel3ammptthemfromand SA4NG POO, CIRIC VALUATION
Ile
<5 the basis for the alleged exemption. Any violation of Section 70115 by any OUTL 1S FIXTUR
O applicant fora permit subject the applicant to a civil penalty of no more than
five hundred dollars($500). NEW I ALELEC STORIES TYPE CONSTRUCTION
I,as owner of the property,or my employees with wages;as their sok
7s, oompensatiun,wUldo the work and thestruesum Is not Intended or offered for III ' 1A A
O ule(Sec.70Z Business and Professions Code:The Contractor's License Law
does not apply to an owner of property who builds or Improves thn ereoand
`3 OCC.GROUP RES.UNFFS
whodoeesuch w not Intelf or nded orwghed ors employee,provided building
or
Improvements are d within
ftornpruk.If,however,r-bul ierwilinga TOTA
Improvement Iswld within oneyes,ro(complelbn,the owner-buUderwill have
ttl,�urden of proving that M did not build or improve for purpwe of elect.- QTY PLUMBING PERMIT FEE
u1,as owner of the property,am exclusively rontracting with l mon FLOOD ZONE APN
contractors to comtmct the project(Sec.7096,Business and Professbru Code: PERMIT ISSUANCE
The Contractor's License Law dm not appty to m owner a(property wha ALTER-DRAIN h VENT-WATER BIM
builds or Improve@ thereon,and who contracts, for such ptojeaa with a FEE SUMMARY
c7atlaeor(s)licensed pursuant to the Contractor's License Law. BAIX FLOW PROTECT.DEVICE
I am exempt under Sec B k P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
• Owner Date RECEIPT M
WORK MAN COMPENSATION DECLARATION FDCrURES PER TRAP SCHOOLTAX Y N
Of hereby affirm that I have•medicate of consent to elf-Insure,ora RECEIPT$
3800,La,C.Workeri Compematlonlrouranceasartified copylhereo((Sec. GAS EA.SYSTEM-1 WG90UTLETS PARK FEE Y N
Policy
fab C.) RECEUPT a
Pollry N GAS EA.SYSTEM-OVER d(EA) BUILDING DIVISION FEES
Com any CertlBed copy Is hercbytd. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified ropy Is filed withh the the city Impaction division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCESEWER-SANITARY-STORM EA.200171. Date Reml t#
UTlseecton need ns,be completed if the permit is forom hundred dollars
($100)mleo') WATER HEATER W/VENT/ELECTx ENERGY FEE Y N
]cattily that eperformance of the work forwhlch this permit is Issued,
I ahan not em ray person in any manner se, t be r e subjecttm the
WATER SYSIFAd/TREATING
worlmn cram firm Lawsof IT"Dam (� PAID
O Z Appllant NEIN RESIDENTIAL PCMB. SOF. Date Recei t#
Z O NX)T[CET A T: act dog this Certificate of Exemption,you
Fshould benne subjM to the lee Compensation provIsless of the Labor TOTAL:
(A Cade,you must forthwith comply h such provisions or this permit shall be
III j deemed revoked. BUILDIN FEE
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby efirce that there at a construction lending agency for the perfomt TOTAL, ELECTRIC FEE
7 Z ana of the work forwhlch this permit Is Issued(Sm 3097,Civ.C.)
U O Lender's Name PLUMBING FEE
IL F Lcuder'sAddrees QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Iartifythmlluvcreadthbapphutionandgatethattheabove Nformutimn
CL korrect.Is,greetocomplywithalldtyandcountyordinanasandeatelaws PERMIT ISSUANCE FEES PAID:
rekauthorize re
ting to Wilding construction,and hereby preeamatives of this
W
[_ city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
eagree to ave,Indemnify and keep harmless the City of Cupertino
Z Date Recei t#
)
' V tllabllltks,judgment,ewteand expenses which may In anyway acme AIR HANDLING UMT(TO 10,000 CPM) SUBTOTAL:
ag t said City I ana o(t granting a Ws,permit.
AIR HANDWNG UNIT(OVER 10,000CFM) CONSTRUCTION TAX
IgnstureofABa / ontactor to EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
A DOUS MATERIALS DISC LO RE
Willthe applicant or future building occupant storeorhandle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
outerlal as defived by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yea rI��1 No
WBl the appllant or lumre Wildingomrpant use equipment mclovices VENTILATION FAN(SINGLE RESID) I$SU
which emit hazardous air contaminants as defined by the Bay Area Air { p -
Quality pFI
Management District? BOILER PDR 100,IXp BTU)
Y. No I2 •7SEP f990
❑
have read the hazardous materials requiremenH under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health k Safety Code,Section 25505,25533 and 25534.I
and tend that If he building does not mrently have a tenant,that it ls my NEW RESIDENTIAL MECH. SQF1 /s, Mas,
res Willy to notify the occupant of the requirements which must be ret N YCPu
pri uarmo atTFINetcofOocIparcy. CN
O,vuxrV.uthmiJlrdag cat Dell ISSUEDBY:
TOTAL:
OFFICE COPY