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21305 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY Building Proect Identification PERMITNO. Building Address: 930 broo 21305 Ph wneraM`e�� 9p� `' A UMWTr— aCITY OF CUPERTINO-BUILDINGDIVISION Conhaaor's Name: 7r LIN . APPLICATION I PERMIT - C BUILDING-ELBCTMCAI PLUMBINC-MECHAMCAL CATEGORY CONTROL X Arc Itect/Engineer. Lk. QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Addreax , PERMITISSUANCE LICENSED CONTRACTOR'S DECLARATION ]hereby affirm that l am licensed under provisions of Chapter 9(,ormumn, APPLIANCESRESIDENTIAL ]OB DESCRIPTION Ingwith Seddon 7000ot Division 3ofthe Bualnesaand ProfaoionsCode,and my C (��, IP licenselsln tali(o and effect .a PANELS 5 ` M Llcruse Class�Lic.X S•'J 7�� Date Contractor UPT02DOAhes ARCHITECTS DECLARATION 201-1000 AMPS R9CO I understand my plans shag be used as Public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT: [G (� Licensed Professional SIGNSELECTRICAL G�< OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC ' Z E,(�'� I hereby affirmthat l am exempt fromthe Contractor'sLicense Law forthe ❑ following reason.(Section 70315,Business and Profealons Code:Any city or F1p"ul county which requires a permit to construct,alter,Improve,demolish,or repair 1'FN'P.MECERORPOLEINST. any stmcture Issuance,to its uance,also requlresthe applicant fee such permit to f5 O E file a signed statement that he In licensed pursuant to the provisions of the POWER DEVICES PWj f. Contractor's License Law with Section 7000)of Divi- SWIMMING POOL ELECTRIC� VALUATION 0 sion3oftheBusinessandProfesslonaCde)arthatheisexempttherefromand the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLE•I.SSWITCF@SFIXTURFS •�-1 ,a"�Q v QQ O applicant fora permit subjects the applicant to a civil penalty of net nnrethan I—V five hundred dollars($500. - NEW RESIDENTIAL ELECTR SQFL. STORIES TYPE CONSTRUCTION �n I,as owner of the property,or my employees with wages as their sok _ compensation,wRldothe work andthe stmeture Is cwt intended or offered for O sale(Sea 7054,Buslneaa and Profealons Code:The Contractors License Law _ 2 does not apply to an owner of property who builds or improves thereon,And OCC.GROUIa RES.UNITS who does such work himself or through his own employees,provided that such Improvements are not Intended moffered tarsale.If,however,thebullding m TOTAL: improvementlsaeldwithlnomyearofcmnpldioMtheowner-buRderwlll have t1o.kurden of proving that he did not build or improve for purpose otsale3. CITY. PLUMBINGPERMIT FEE FLOOD ZONE APN Lj I,as owner of the property,am exclusively contracting with licensedcontraPERMIT ISSUANCE' ^'l TheContratoconsWRtheproject(Sec.704kapply Businessnand of property Cade: sL� The Contractor's License Taw does not apply tct an owner p property who ALTER-DRAW&VENT-WATER(EA) Wilda or Improvn thereon,end who contracts fm each plajecte with a gjjt (-)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT. FEE SUMMARY mI am exempt a er B &P C for this reason OUTSIDE FEES - Owner DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N Doh RECEPTX x WORKMAN COMPENSATION DECLA A ION l FIXTURES.PER TRAP SCHOOLTAX Y N QI hereby affirm that I have a cerlNwte of consent to self-Insure,ora � � RECEIPT X '- certlBrate of Werkers'Compensation Insurance or a certified copy thereof(Sec. 3808,Lab C.) GAS FM- EA.SYST1 INCA OUTLETS PARK FEE Y - N Pollry p RECEIPT N CAS E.A.SYSTEM-OVER 4(EA) Com any - BUILDING DIVISION FEES CertNed copy ls herebyththe GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECICFEE Certified copy is flied with IM city ty Inspection division. ' CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-S]DAM EA.XIOET. Date Recei t# Cfhlssectlon ne d not be completed If the permit isforom hundred dollars ($1000 IAllyth WATER HEATER W/VENT/ELECTR ENERGYFEE Y N Ior lnthe performance o(thework lorwNch this permit is sad, I shall not empbayof person N any manner w as to beco the ' Workers ComQ��[q�lo Tawe ( Date © Q WATER SYSTEM/TREATING PAID O Z Applicant Z O NOTICE TO APPLICANT:�M:If,after mall g thin Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFF. Date Reeei t# should become subject to the Workers Compensation provisions of the Labor - TOTAL: N Code,you moat forthwith comply with such provisions orthls permit shall be >' deemed revoked, - BUILDING ELE W CONSTRUCTION LENDING AGENCY SEISMIC FEE a1hereby afRrmthatthen isamnstmetionlending agency for the perform �p� ELECTRIC FEE Z onceofthe work for which this permit is Issued(Sec.3097,C1v.C.) TOTAL; I W U s� O a Lender's Name ` PLUMBING FEE IL 1- Lender's Address - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE O,W ce I nifythatl have read thlsappliationand state that the above Information a Lamrred.Iagreeto complywith all otyand muntyardlnanmsandestelaws PERMIT ISSUANCE FEES PAID: } UI relating to building construction,and hereby authodae representatives of this F—rZ city to enter upon the above-mentloned property for Inspection purposes. ALTER OR ADD TO MECH. (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt# against liabilities,Iidgments,costs and expenses which may in any way same AIR HANDLING UNIT(TO 10,000 CFM). SUBTOTAL: ago t - d City in corse race of the granting of this permit. �o AIR HANDLING UNIT(OVER 10,"CFM) CONSTRUCTION TAX Ig tureof Applicant/Contractor ae E(RAUSTHOOD(W/DUCT) - - CONSTRUCTION TAX PAID: HA2ARDOUSMATERI 'DISCLOSURE Will the appBrantmfuture building antamreorhandlehasardoua HEATING UMT(TO 100,000 BTU) material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Recei t# He❑alt hand Safety Coe,_SeN�on 25532(a)P HEATING UNIT(OVER 100,000 BTU) TOTAL: Will the applicant or❑❑(afore building acevpant use equipment or devices VENTILATION PAN(SINGLE REBID) aetaplB�7a]ANCE DATE ' which emit hexardous air contaminant,as defined by the Bay Area Air �.J y[J silty me Managent DiAHd? BOLL ER-COMP(3HP OR 160,000 BTU) Yea n No 1, acmadthehazarousmtcrialsrequlrementnunderChapter 6.95of BOILER-COMP(OVER 100,000 BTU) ( a. the California Health&Safely Code,Sections 25505,25533 and 25534. I \;1 understand that lithe building does net currently have a tenant that it is my NEW RESIDENTIAL MEIN. SQ.FT. responsibility to notify the occupant of the requirements which must be met prior to Issuance of a Cerifi ate of Oavpancy. Owner or authorized agent Date ��'1�sf' ' TOTAL: ISSUED BY:�a V N-1 N\C� OFFICE COPY