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21457 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —,USE BALL POINT PEN ONLY Building Project Identification PERMIT NO. Building Address: - - - 214 5 7 am. A A 73,5`07CITYOFCUPERTINO-BUILDING DIVISION - Coutadnr',N n,e, may, Lic.No: / APPLICATION I PERMIT L I f m -v 7;te / �.2�7 3ey"� BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL ArchlteR/Engineer. - Lie.No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: - PERhOTISSUANCE ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION I hereby affirm that l am lcensed under provision,of Chapter 9(comment, APPLIANCESRESIDENIAL - JOB DESCRIPTION with Section 7000)of Divislon3 ofthe Business and ProfeesionsCode,and my I� I" is In fuprforq deffeR. �s b PANELS License Clam S 3 Loc.B a� 3 O Date ntractor £•v20 ARCHITECT'S DECLARATION 201-IODO AMPS O O I understand my plaru shall be used m public recd ds. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT. Licensed Profemioml SIGNSELECTRICAL OWNER-BUILDER DECLARATION SPECIAL CIItCUfT/MISC ZE, IherebyafBrmlhat lam exempt from the Contractor's License law for the Wfollowing reason.(Section 7031.5,Business and Professions Code:My city or O Z t� TEMP.METEROR POLE]NST. p� county which requires a permit to rorutmet,alter,Improve,demolish,or repair q anystm=mprlortolbbauance,aatorequre stheappliantfmsuchpermltto POWER DEVICES q file a signed statement that he at licensed pursuant to the provisions of the _ 006 1I.� Contractor's Deems,law(Chapter 9(mmmene ng with Section 9000)of Divi. SWIMMING]VOL ELE C5[ . VALUATION slon3ofthe B.,I rind Pro(emloru Code)orthatheiaexempttherefmmand y, , a.••777 the bash for the elkged eaemptlon. My vlolaHon of Bectlon 7031.5 by,any O OA appliantfora permitsubjeMtheapplkanttoa civil penalty Dino[more han ' �c five hundred dollars(¢500). /- '9..' ❑I,as owner ll the property,or my employees with wages r there wk NEW ELECTR A SQ.Ff. STORIES TYPECONSTRUCTION romperea 044,Business and Prwork ensionsmde:Theime CHtractodorcense d forLw ,�2. EO ale(Sec 7064,Business and Professions Code:The Contractors Llarue Law '�does not apply to an owner of property who Wilda or Improves thereon,and OCC.GROUP RM UNITS EE whod°essuchworkhlmmlforthroughhlsownemployeea,providedS tsuch , improvements are notintended oroffned foreale.If,however,thebulld or Vl`b P OTpl; Improvementissoldwithln mayearofcomplatlon,theowner-WBderwlll ve t} uMen of proving that M did na build or Improve for purpose of ). Q , PL BINE PE FEE u FLOOD ZONE - APN Lor owner of the property,am exclusively attracting with Ilce . p A p�H gNCE 1 rontractore to wrwtmR the project(Sec 7016,Business and Profealoru C L\0 4 A , •The Contractor's License law doe,not apply to an owner of property he - ALTER:DRAIlY&VENT-WATER(EA) Wilds or Improves thereon,and who moment for such p(ojem wit a ffctor(s)licensed pursuant to the Contrador'e Llanm Law. FEE SUMMARY c LJI am exempt under Sec B&P C for thio remora B Ck FLOW T.DEWCE -'t r SANITARY y .N_ - Date D NS FLOG R F, RECEITTp Owner IEA.��. WORKMAN COMPENSATION DECLARATION FL((TTIiES PER SCHOOL TAX Y N 01 hereby affl.that I have•certificate of consent to self-Insure,w a RFC®rl M artNcate of Workem''Compereati°nlrammace or a certified copythrmof(See. GAS a SY -1 INC.40UTLEIS PARI(FEE Y N 3800,Lab CJ Pollryk RCErPTF--- C- say Csay G EA. STEN-0VER4(EA) BUILDING DIV ISION FEES ❑CedNed copy at hereby te Certified copy Is Ned withh the city Impaction division. GREA /INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE " ❑ ty CERTIFICATE OF EXEMPTION FROM WORKERS' GREAS ]RNs PAID COMPENSATION INSURANCE SEWER- STORM EA 200FT Date Recei I# Ohlseection need n°[W complded BtW permit at(w oro hundred dollars (8100)alem3 WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N Icertifythat o the performance of the work so as hich to become Ic leo the I shall not employ any Uws In any manner m n to berome aubjed to the WATER SYSTEM/TREATING Workerv'Compenatlon Law,o(GII(ornh. Date PAID 0Z Applicant NEW RESIDENTIAL PLMB. SQFf. Date Recei f# Z O NOTICE TO APPLICANT.If,after making this Certificate of Faemption,you - Fshould become subject to the Workers'Compensation provatloru o(the Labor TOTAL: f/) Code,you must forthwith comply with such provisions or that permit shall be W > deamed revoked. BUILDING FEE CL G CONSTRUCTION LENDING AGENCY - SEISMIC FEE Ihembyafftrm that there b a construction lending agency for the perform- - - ELECTRIC FEE D Z anceoftheworkforwhichthatperMti.at, ec d(S .3097,CIv.C.) TOTAL; 02 Larders Name PLUMBING FEE LLF- Lender'a Addm.s - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE O W ImAifythatlhavereadthbappUmdonandrtatethattheaWvelnform,tion IL is sorrel[lagreeto complywlthallRtyand county ordinances and nate laws PERMIT ISSUANCE �� FEES PAID: >. relating to building constmotion,and hereby authorize representatives of this Zcity to enter upon the abovcmentioned property for Inspection purposes, ALTER ORADDTOMECH. - Date ReCei t# V _ (We)agree to amkeep save,Indemnify an d p harmless the City of Cupertino P against 11 'Ides,judgments,mets ands Rses which may In any way accrue AIRHANDLINCUNIT(TO10,ODOCFM) SUBTOTAL: against City Inrone tin his permit - `/y' AIR HANDLING UNIT(OVER 10,000CFM)' CONSTRUCTION TAX 2ZofA Rant/Contra for Date D(HAUST HOOD(W/DUCT) - CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE �s 7711 the applicant or hmm,building occupant store or handle hazardous HEATING UNIT(T0100,000 BTU) - Date Recei t# material as defined by the Cupertino Municipal Code,Chapter 9.12,and the �y Fla❑lt and Safety Cade,Sectoon 25532(.)7 HEATING UNIT(OVER 100,000 BTU) . OTAL: LYJ Will the applicant or yen ❑❑future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) U_ . CEDATE which emit hazardous air contaminants as defined by the Bay Area Air I©lr Quality Management District? BOILER-CAMP DHP OR 100,0(10 BTU) lr ❑Yn F�No f ]have readtheharamousmateriali requirements under Chapter 6.95 of BOILER-COMP(OVERI00,DOOBTU) . the California Health&SafetyCode,Sedlona 25505,25533 and 25534. I underetafin d that lithe building donot cumentlyhave a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. 0Pit) "o responsibility to notify the occupant of the requirements which must be met prior to Issuance of a Certificate ofOmpanry. Owner or authorlud agent Data ISSUED gY.\ F7)�:- TXIkV V'�Cc TOTAL: d OFFICE COPY