21838 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
-Building Project Identification / PFRMITNO.
Building Address:
y P,, LAI 21838
wG/7'�Aa�n1e�: !// -- ,, / �rJ�SeZ4QO A A A
CITY OF CUPERTINO-BUILDING DIVISION
Coet.ctor.N.me sacs Na: APPLICATION I PERMIT l y
rt BUfLDINGaDCTRICALPLUMBING-MMMCAL CATEGORY CONTROL N
Arch gln¢r. Lic.Nn
�T•a+"/
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addresv
LICENSED CONTRACTOR'S DECLARATION
PERMTISSUANCE 1J— D-
i{
-
IMremmthatl amkensed under provisions ofChaper9( APPLIANCES-RESIDENTIAL JOB DESCRIPTION
I5ectiom0)0l gvlslonl.IthegudnessandProfeulon.Cndgardmy
It...1s In f'll
/or¢Anyl dfM�v, PANELS
Date Clas��" LImN
Date
Contractor
ARCHITECTS DECLARATION 201.1000A.MPS
qqq XzC Iunderstand my plane shall M used s publIerecmds. OVER 1000AMPS SQ.FT.FLOOR AREA $/SQ.FT.
00
'd6 Licensed Professional - SIGNS ELECTRICAL 2
6 OWNEILBUILDER DECLARATION SPECIAL CIRCUIT/ML5C
7MF, Iherebyafflrm that lam exempt from the Contractor's License law for the
«:o following reason.fSenlan 701.5,Business and Professions Code:Any dy or
F rLn f'� countywhlchrequlresaperrrdtt.mytrud,alter,tmpmve,demolbh,urmpair TEMP. E SF
�^ anystrudu¢priorto its issuance,alorequire.theappliant for such permitto PO
ryG r. file a sired b
�ed statement that he licensed pursuant to the proviesc of the WER EVI
3w� Contractors License Law(Chapter 9(mmmendngwith Seed
on70W)o(gvl L
E, 11on3.fthe Business and ProfessionsCade)orthat he Ls exemptthemfmmand VALUATION
Wait a.•--tt the hufor the alleged exe.ptlw. Any violation of Sectio 7MI.5 by any OU7LETSSH
WITCESFI '
appllcantfora perMtwbjats the applkant toadvll pevlty of not.rare thin t 8��
$ five hundred dollars($500). NEW AESID
EPAR
?G ❑I,as owner of the property,or my employees with wages as their sok RIES TYPE CONSTRUCTION
compevatlon,will do the work and thestroctureb not Intended or offered for
5` ❑ sale(Soc.7014,B..lnea and Pmfe.e.Cade:The C.etradoe.Llcense Law
$ does not apply to an owner of property who builds or Improves 1Mreon,and
a whodoessuchworkhlnuel/orthrough hlsown employees,provided that such OCC.GROUP RES.UNITS
Improvementsare not Intended proffered foreale.K however,thebullding or TOTAL:
Improvement lasold within oneyearofcompletiogtheowner-bu0derw111 have
tli,,kardeno/provingthat he did not build or improve forpurpo.e efule.). QTY. PLUMBING PERMIT FEE FLOOD TONE APN
IJ L as owner of the property,am exclusively contracting with licensed
contract..to construct the project(Sec.7044,gust..and Ps esions Code: PERMIT ISSUANCE
The Cont.ci.rb License law dm net apply to an owner of property who ALTER-DRAIN 4 VENT-WATER(EA)
loWild.or Improv¢ there., and who contracts for sued p�oFsts with a
co ctor(s)B¢nsed pursuant to the Contractor'.License Law. BACK HAW PROTECT.DEVICE FEE SUMMARY
L�I am exempt under Sec. B 4 P C for this masnn
DRAINS HOOT{ROOF,AREA,OOND. SANITARY Y_ N_�
Owner Date RECEIPT
WORK MAN COMPENSATION DECLARATION FE)MMI_S PER.TRAP SCHOOL TAX Y_ N_
❑1 hereby affirm that I have o Insurance
ate of consent to copy
ytweof ora HE=N
3800,cor"fiabte ofWorkeri Compeneatloninsuran¢ors¢nRled copythetwf(Sec. GAS EA.SYSITM-1 INCA OUTLETS PARK FEE Y N
3800,lab C.)
Polity N GAS EA.SYSTEM-OVER I(FA) DING DIP`F N
Com any BUILDING DIVISION FEES
mcenlfied copy la herebyfurnished.the cid. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
❑cenmed copy b need with the city Inspection alma...
CERTIFICATE OF EXEMPTION FROM WORKERS• GREASETRAP PAID aye
COMPENSATION INSURANCE SEWER- STORM STORM E.A.2(pFT. Date Retmi Hf
(Fh1.aMlon need nes M Completed If the permit is/or one hundred dolls.
(5100)orlesJ WATERIIEATFRW/VENT/EIECTR ENERGYFEE Y _ N_
I certify that o the performance of the work as to h this permit is tented,the
I shall not employ any pawn In any manner n s m become eubjeR to the WATER SYSTGI/TREATING
w.rkc�c.mpen,an.n Laws.(caur.mla. Data - PAID
O Z NOTApplICE` If, NEW RESIDENTIAL PLMB. SQ.IT. Date Recei ted
ZO NVuld beVMI'LICANT:e ager rra'Co thisCertificate
pro o(ExempteLyou
should Code,you=a subject to the Workers'Comp mats.n s.,th one of the Labor TOTAL:
W~ W deemed uvoked.forthwith comply with such provlalone arthb permit shall be BUILDING FEE 4,D
> deemed revoked.
CIL 3 CONSTRUCTION LENDING AGENCY SEISMIC FEE .OZ
Ihambya(firrethatthe¢baconstru on lend lngagen" for the perform- ELECTRIC FEE
Z anceoftheworkforwhlchthis pe ued t5ec.3097,CIv.C.) TOTAL: O.
V O Lander.Name PLUMBING FEE 7Q.
LL Lenders address - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE 7p _
WO I cortlfythat l have mad thlsa pllatlon and tatethat theaWve Information
lacorec.l agree to comply with all city and muntyordinanc¢and tate laws PERMIT ISSUANCE FEES
} W mlatingtobulldingmmtrudlon,andhe.byauthorlmcepre.ntativesofthla
F In city to enter upon the abovcmentloned property for inspection
te Redion purposes. ALTER OR ADDTO MECH. DaO
— (We)agree to save,Indemnify an d Exp harmlessthe City of Cu pertlno P
against liabilities,jad Is,cot, dupe a which may In anywayacwe AIR HANDLING UNIT CFO.10,006 CFM)
.gatnetsald rl 'e Ing Ing of this permit SUBTOTAL:
AIR IIANDUNG UNIT 14MCiM) CONSTRUCTION TAX
Sig pliant/ anvad.r Rate EXHAUSTHOOD(W/DUCT) C �PIONTTAX P ID:
=RDOUSMATER I A L S DISCLOSURE I� / �(y�
W ri cllant or future building occupant store or handle hazardous HEATING UNIT(10100,000 BIM Date Reset til
rvter lasdaflnedbytMCupenin.Municipal Code,Chapter9.12andthe
rleshhere5afdy Cade Secti.e25532G)2 HEATING UNIT(OVER 100,00)BTU) TOTAL: AS
❑Yes r]No
Will the applicant orfuture building occupant use equipment or devices VENTILATION FAN(STNGLERESID) I$SUA[xL(.E1Q,TE
which omit haz rdousalr contaminants..defined by the Bay Area Air - 'Ray's .)
Iity Management District? BOILER-COMP OFB'OR 100,000 BTU)
Yes 11��1 No FEB
a have mad the hanrs�ou matenab mqulremants under Chapter 6.95 o! MOILER-COMP(DVE21 04,000 BLV) 'G 1 \ 1
the Glifornla health 6 Safdy Code,Sedioru 25505,25533 and 25530.I r
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECFL S'Q.ET.
responsibility to n the mpart of the requlremn.ts wh ich ustbemet
prior to isuan t dI0 panty. ^^����\\ - l'041 ,
Owner or aul dagent '
Daft— ISSUEDBY:�J_s�—w\AM{[�
TOTAL:
OFFICE COPY