21623 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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Building Prom ldeml(loaon
L PERMIT NO.
Building Addee
rr �� W000 LLT 21623
l7- (s00Jg CITY OF CUPERTINO-BUILDING DIVISION I --.2.—q I
Contnanr'• arne NoIcn APPLICATION / PERMIT
ArchltM/Engfncer.1. BIRll] ELECTRICALI'LUMBINGMKL LAICAL CAITGCRY CONTROL;1
Llc
'1SS C L O { C�.3 QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address I'FRh9TIS5UANCE ® §�
LICENSED CONTAR
CONTRACTOR'S DECLATION LOQ
I hercbyafr7E thetlunllcenuduMerprwWw•dClupca9 de,and is APPI.IANG6RESmEIvTIAL JOB RIPIION
Ingwlth Sectbn70W)of Divlatm3 ofthe Buelrcsasnd Profosbna Code,and my
Iiceae b In fail(pRxand dfcR r r�,..,,p•••y P ^ (� I �•.
Lkxnse Close IQ I,#-tel."/.-+� L 1 N II V S t^ Uj 1
Date Contractor �..J l.r
ARCHITECT'S DECLARATION '1
�2 I understand rrry plans shag he used n public records. OVER �I SQ.FT.FLOOR A/rREE S/SQ.FT.
Clawed PedesebvlSIGNS ELECT?
OWNER-BUILDER DECLARATION SPECIAL CBC UR/
I hereby afirrnthem
t laexempt feerntheContractor'sLicense LAwfothe L,/
following reason.Scold n70715,Basinand Profmloro Code.Anycityor L% b
O TEMP.MFDR OR POLE INST.
p� muntywhldi requ4esapemYttomvtruct,dter,Impmve.demoWh,orrrpdr
anystructvrt pnorm ltslmrarca,aleorequlrts theappBant for such pemdt to POWER DEVICES .
5 file•signed mmb rsbro
teent that he licensed pursuant to the prorisof the
Contractor's lJceroeLaw(Clupter9(mmmendng with Section 7000)daVf- SWIMMINGPOOLELECTIZIC
sbn3 of the Bushes,and Professions Code)or that he b exempt therefrom," VALUATION
othe bash for the alleged exemption. Any Wdatbn of Section 70315 by any DUnuisSWI.ICI aSFD(TURF_S "7s.
A applicant fora per .b*e the,ppB ttoativllpevhydndmmethan
$ MffundrM ddlu•(f.SWj. NEW RESIDFMIAL ELEM SQ.FT. STORIES TITE CONSTRl�T10\
Lf I,a r owrrof the property,or my employees with wages as their sole
mmpevatlon,will dothe wak,nd the structure b rn1 Wendel or offered for
Osale Ck,7044,Bus1rem;and Pri fembro Code:The Contractor's Uaroe U.
�$ don not apply to an owner of property who builds or improves thereon,and - OCC-GROUP RES UNITS
who done such work hrom
belf through Itsown employ eea,provided that such
bnprovem armor'Intendedorofferedfreak.Ilhowever,the WIldingm TOTAL:
Improvement band within one yearof completion,the ownabu Ilder velli have
t"reien of proving that he did not Wild or Improve for purpose or sale.). QTY, PLUMBING PERMIT FEE
u 1,as owner of the property,am exciwh<ly contracting with Barged FLOODZONE AM
cntnctmatamvtruathepm}ea(Sce.7E)K Buslnemand Proferobro Code: PERMITLSSUANCE
The Contractor's License Law does not apply to an owner of property who ALTFA-DRAIN k VFM-WATER(EMW Ilds or Improves thereon, and whn contracts for such ptojem with
ogat(,�W.)Bossed pumaat to the Contractor's License I.. FEE
FLOW PROTECT.DEVICE FEE SUMMARY
LJ I ire--e-pt under Sec B k P C for tIW reasonOUTSIDE FEES
Owner Date
DRAINS FLOOR ROOF,AREA,CONED. SANITARY Y_ N
RBCF]I'I'
WORffBenm host ht COMPENSATION DECLARATION 01 PER.TRAP SCI1OOL TAX Y_ N_
❑1 hereby aI have a anlBate d consent to self-heart,or a
RECFF]pII's
certificateof Wotren'Compevatlon Insurance as anifled copy thereof 6ec. GAS FA.SYSTE]N-1 INCA OUTLETS PARK FEE Y_ N_
3800,Wbb G)
I dfcy Y GAS EA.SYSIFA/-OVER 4(FA) RECEIPT a
Com v a l 1 i BUILDING DIVISION FEES
Cathed copy b heed with the cit. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECR FEE
copy Is(Teed with the tlty inspection dlvW m.
CERTIFICATE OF EXEMPTION FROM WORKERS FAID
COMPENSATIONmcefft INSURANCE SEWEILSANTEARY-MRM EA 2XFT Date -RCceI tlt Sl .ly
(IhorI..) nttd nUhecompicted lithe pemdt bfaone hundred doWre
C51 WE ImAife.J WATER HEATERW/VENT/ELDCTR ENERGY FEE Y N
lllnet that In err peramanaof thewart ler whichco nesmkbbled,
1 shag not employ any Laws f any,rtnnner at a b become subject to the WATER SYSTEM/IRFA.DNG
Wwlicn'Cmnpensatbn l.w.of California, Dale PAID
O Z NOTICApplicaE TO
ion,you NEW RMDENTIAI.PIMB, SQFI'. Date Recei of
ZO NOnCEourre subEect M:eWorkrs'Come atiulatedoiempteLabo
should hemme subject it the Workers'such p roatbn provbira of the tabor TOTAL
�~ N Cedq you ,ked. hwhh comply with such proWbro or this per-nut slullhe eO
) desnrd rewked. BUILDING FEE
CL O CONSTRUCTION Laction CG AGENCY SEISMICFEE 3
Z Ihercby ork'Euhe hieh acoeatmctlaa le"logo ,Ch'.r the penorrry TOTAL ELECTRIC FEE
aceof er'.N, ort for whlols thiope rmttbwaed(�-309'7,CN.GI
LL O lender's Name ()In PLUMBING FEE
LL F lender'.Aaaree, QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Tanlfy thatlluve read title pllatbna"atatethat theabovelnfomatica
bmrmr.lagrteb comptywM,uctly,nd musty nedwnrn adstale low. PERMIT ISSUANCE FEES PAID.
} a rdatl entern One
corotmctiw,,"hereby rty orb<reptio ntatNn dthio
N M(Wenteree to uve,in ere�ntbn i keep
fairope Cit purposes Caper ALTER OR ADDTO MFi1i.
? (We)agree to save,WemMty an d keep harmlese the City o!Cupertino Date Recei to
V against Wbilitles,NdM
grnea,costsand esperues which nay, ,n
in SUBTOTAL-_21918V
AIR HANDLING UNIT CIO 10,000 CFM) SUBTOTA1
against said City In consequence of the granting d thisN
AI
A
`R, R IIANIRINCImTT(DYER]O,DDOCEM) CONSTRUCTION TAX
Slgvturt fAp cant/contractortr,aractor v fI1�-/IDate D(HAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MA RIALS DISCLOILRE
WDl the appllantafuture Woding oovpant port ur ha"khavedmrs HEATING UNIT CIO 100,000 BTU) Date Recel t# 9, I
malenal a defined by the Cupenlw MuNdpal Code,Chapter 9.12,and the
1 @alth a"Safcty Code Section 2S532p)7 HEATING UNIT(OVER 100,D00 BTU) TOTAL:
T4 Yes q
Ill the applicant or future building occupant <qulpmcM or VENTILATION FAN(SINGLE RESIDE
SS'}t DATE
which emit harardous air conaMranb as defy by the Bay Area Air
Quality MavgemeM DWric7, BOILER-COMP OTB'OR 100,000 BTU) r--rsa l 15�i
❑❑N
4Yes o hvercadthehaudmarea, egUcmnbunderCnperG95of BOILER-COMP(OVER 1W,"BTU)
the Csbfomh Health k Safety Code,SMbro 25,50$,25533 and 25534.1
undmtandthatifthe WBdtngda =m mntlyhave,tenanLthatitbmy NEWRESIDENTIALMECH. SQ.FT Nha�(stTnw.• -1
mpoaibilNytondifythe.pantdthercquirt Mswhich.wrt tr et 11NJ ,
prior to Iseuaruc d a Cinllhte of Omvpamy.
f ` tax
Owner or authoahued agent m TOTAL: ISSUEDBY:
OFFICE COPY