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21045 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY Building Proed Identification - PERMIT NO. Building Address: � - 21045 ne c onep CITY OF CUPERTIN0.BUILDING DIVISION 7—�� . •� �. DAIL Ile Cont, or. mi '.Nae: _ LIc.N. APPLICATION /PERMIT Co L l BUILDING-ELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTRO N'el Lk.Nm IL V 0. Lel QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address (It,� � �j PERMITISSUANCE 2CZ1 � 11 1:1LICENSED CONTRACTOR'S DECLARATION I hereby affirm that l am licensed under provlsleas of Chapter 9(comemerso APPLIANCFSRESIDENTIAL JOB DESCRIPTION ingwith Section700D)of Dlvlslm3 ofthe Buslnemand ProfessionsCode,and my DateIt ie in fu force and—L�ct.N a.-{ 5 / PANELS Llmnse C6m 70 b Dale Contractor 7011000 AMPS ARCHITECTS DECLARATION IQ+�Oce oqz2 I unde,etand my plass shag be used m public records. OVER IOW AMPS `SQ.FC.FLOOR AREA $/SQ.FC. F o U Lies sed Professional SIGNSELECTRICAL «<<6 OWNER-BUILDER DECLARATION SPKIALCIRCUIT/MLSC z.' Iherebya(firm that[assexemptfrmnthe Contractors LicenseLawfmthe ' p following reason.(Section 70'315 'A ,Business and Profmatom Code: city or rA q cnuntywhlchrequrc apemdttomtutr mOter,Impmve,de=lish,orrepalr TEMP.METER OR POLE INST. `'0 76 anyatru mprimwltaimancealsomqulrestheappHantfwr chparMtto POWER DEVICES V file a signed statement that he is licensed pursuant to the provisions of the Contractor.License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC thOJ tlon3otlhe Businesaand PmfmionsCode)orlhathelsewmptiherefmmand VALUATION {''� the beds for the alleged exemption. Any violation of Section mat room by any OUILE.ISSWITCHFSF[XIURES \ O Q� applicant a permit subjecia the applicant to o civil penalty of not more than J flue hundredsowner the pro NEW RESIDENTIAL ELECIR ❑!,as owner°(the property,or my employees with wage a Itself sole �Q �'�' STORIES TYPECONSTRUCTION a compensation,wfildo the work and the slrucu,e isnot Wended or offered for UV�{'LA ❑ sale(Sec 7064,Business and Professions Code:The Contractors License Law $ sqcv does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RFS.UNITS who doessuch work himself orthmagh his own employees,provided that such 7a Improvements are not Intended or offered for mix,It,however,the building or TOTAL: Improvement is Sold within one yea rofcomplellon,the owner-bullderwill have ttlR-purden of proving that he did not build or Improve for pu rpose of sale.). QTY, PLUMBING PERMIT FEE FIpOD?ANE. APN LJ 1,ae owner of the property,am exclusively mntracting with licensed contractors to censttuct the project(Sec 7044,Business and Profemlons Code: PERMIT ISSUANCE The Contractor.License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA) Wild.or Improve,thereon, and who comment for such p(ojects with a FEE SUMMARY xq)tipaaor(s)licensed Pursuant to the Contractors Llcenm Lew. BACK FLOW PROTECT. IJ 1 am exempt under Sea B k P C for this reason OUTSIDE FEES SANITARY Y N_ Owner Date D , R'R F' RECEIPT N WORIG6AN COMPENSATION DECLARATION FIX^ SZbi l7 .�. SCHOOLTAX Y N -- ❑I hereby aBlnn tha I have a mrtifim to of consent to selbinsure,or RECEIPT N '- mrtl(IoleofWarken'Comperualion lnsurancearacertlfled mpythemof(Sec. G .SY.$ITM-lil' S� I PARK FEE -Y N 3800,lab C.) RECEIPT N Policy N x yGAS -OV 4BUILDING DIVISION FEES izxd copy la herebyth the city /ADu PLANCHECK FEE rtmea copyls(ibd with the city lnspMion dlWelan. �/ CERTIFICATE OF F3(EMPFION FROM WORKERS' GREASETRAP PAID Y0 COMPENSATION INSURANCE' SEWER-SANITARY-STORM FA.2007r. Date Recel IN Q (TMaaenian need not be completed lithe pemdl isferons hundred dollars (5100)°`1`®') WATER HEATER W/VENC/F1.ECTR ENERGY FEE Y N I certify that In the performance of thewmk forwhlch this permit is based, I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING . Workers'Compensation Laws of California.Date PAID O Z Applicant NEW RESIDENTIAL PLMB. SQ}T. Date Recei tN Z O NOTICETO APPLICANT.If,after making this Certificate of Exemption,you shmld become subject to the Workers Compensation provlsloce of the Labor TOTAL: IX N Code,you moat forthwith comply with such provisions orths permit shall be B I .CR? W > deemed revoked. a O CONSTRUCTION LENDING AGENCY SEISMIC FFE I herebyNBrm that them is a construction lending agency for the perform- TOTAL: ELECTRIC FEE co M 0 once of the work for which this permit is Issued(Sce.3W,Civ.C.) lender's Name PLUMBING FEE LL F Under',Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE OW .l certitythat l have reacithls oppBmtionad statethm theaboveInformation 6 iscerect.I agreeto comply with all city and county ordinance and pate laws PERMIT ISSUANCE FEES PAID: relating to building commaction,."hereby authorize representatives of this N F city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH. ? (We)agree to save,Indemnity an d keep har less the City of Cupertino -Date Recei tN V against liabilities,judgments,mstaand expenses which may in anyway..c AIR HANDLING UNIT DO 10,000 CFM) SUBTOTAL: against said City in consequence of the granting of this permit. AIR HANDLING UNIT(OVER IO,WOCFM) CONSTRUCTION TAX Slgnamrx of Applicant/Contrantor Data IXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HATAR DOLS MATERIALS DISCLOSURE Will the applicant orfutum building occupant store or hand in hazardous HEATING UNIT(TO IDIOM BTU) Date Recei tH material as defined by the Cupertino Municipal Code,Chapter 9.3 2,and the Heallhand Safety Code Sectlan2S532(z)? HEATING UNIT(OVER 100,000 BTU) TOTAL: ;L ❑Yea MN. r��n' Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) �DATE whichemitF.vrdoue air contaminsnn ae defimd by the Bay Area Air Quality Management District? BOILER-COMP(3HP OR 100,000 BTN r'//Y� Yee ous11 V haveread the haza malsrials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,0(10 BTU) 4 QnQ he Gllfomia Health A Safety Code,Sectio.25505,75533 and 25534.1 /uta VkT understand that if the building does sot currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. responsibility to notify the occupant of the requirements which must be mel price to issuance of a Certificate of Occupancy. Owner or authorized agent Date TOTAL: ISSUEDBY OFFICE COPY .