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21311APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY Building Protect Idemificatlon Building Address: PFEMITNO. a e«•�. cL� 21311 nerd ansa: .J 4� h bs one: • .J a or. ams !� tui ^ CITY OF CUPERTINO-BUILDING DIVISION APPLICATION I PERMIT BUR.DINGTR ELECKALPLUMBINGM HANICAL / _� G•2r q, 0 l CATEGORY CONTROL a A Ited/En neer. Lt.. No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO !` Address: h I PERMfTISSUANCE LICENSED CONTRACTOR'S DECLARATION I hereby affirm that am licensed under provisions of Chapter9(commen Ingwlh Se Wn7000)of Division3aflhe Busimmand ProfenimsCode, and my h=le Infol rce tidied. o Limn:Class = LICN L APPLIANCESRESIDENTUL a� JOB DESCR2N K� l • 1`nLLJr�"� PANELS Date ped" .0 < 4 �+•t L —(,«� Al -1000 AMPS ARCHITECT' 'DECLARATI I understand my plans shag be used a public rec rds J 1�` OVER 1000 AMPS SQ. Fr. FLOOR AREA S/SQ. Fr. SIGNS ELECTRICAL Licenced Pmfesalaml SPECIAL CIRCLIT/MISC OWNER -BUILDER DECLARATION I hereby affirmthat I am exempt from the Contractor's LWeme Lw forthe - TEMP. METE OR following reason.(5ection 7031.5, Business and Professions Code: Any city or cmntywhichmqubeaaper twmutmd,dter,Improve,de=lWh,orrepalr . anystructure pdorto its Issuance, ahorequireslheappliant forsuch permit to Me a signed statement that he la licensed pursuant to the provisions of the Contractor's License Law (Chepter 9 (commencing with Section 7000) of Dlvl- sion3 ofthe Business and Professions Code) cribs, he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by an applicant for a permit subjects the applicant too dvil penaltyofd ..the. !OWER DEVICES gWA1ARNG POOL ELECIRI I OUTLETS-SWRCI{E9-FIXTURES ' V VALUATION ry ©Q C j, b V five hundred dollars (31M. ❑ I, as owner of the property, or my employees with wages as their sole NEW RISIDENTIp EL TR STORIES TYPE CONSTRUCTION compensation, will do the work and the structure is nm intended or offered for sale (Sec. 7014, Business and Professions Code: The Comradors License law does not apply to an owner of property who builds or Improves thereon, and who dcow.ch work himself., through his own employees, provided that such OCC.GROUP RFS. UNITS Improvements are not Intended proffered for We. If, however, the building or Improvement build within amyearofcompldlon, the owner-bullderwlll have OTAL A tMrdenofprovingthat hedld not build or Improve for purpose ofsale.). [_f 4 as owner of the property, am exclusively contracting with licensedFiWD mntradonloaonelrudhe project(Sec70K Buslnessand Professimu Code: QTY. PLUMBING PERMIT FEE IDNE APN PERMITSSUANCE The Contractor's License Law does not apply to an owner of property who Wilda or Improves thereon, and who common, for such pAo)eds with a u actm(s) licensed pursuant to the Contactors Lt... I.. LJ I am exempt under Sec g & P C for thin reason ALTER -DRAIN & VENT - WATER (EA) FEE SUMMARY BACK FLOW PROTECT. DEVICE OUTSIDEFEES DRAINS. FLOOR ROOF, AREA, COND. SANITARY Y_ N_ RECEIPT« Owner Date WORKMAN ORKAN COMPENSATION DECLARATION rtlte of consent to self-inre, a C31 hereby afflrtn that I have a orfiawm certlflaCfWorkeri Compensatlanlnsunncemacertlfled ropy[hereo((Sec. 3800, Tabb C.) PD(TURES PER TRAP ' SCHOOL TAX Y_ N_ RECEIPT' « GAS EA. SYSTEM -1 INCA OUTLETS PARK FEE Y N RECEIPT « Poliry« Com any GAS EA. SYSTEM -OVER BUILDING DIV1510N FEES . �Certlfied copy is hereby fumshed. ❑Cenifled copy la filed with he city Inspection division. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE GRFASETRAP CERTIFICATE OF IXEMFHON FROM WORKERS' PAID COMPENSATION INSURANCE (Thissedlon need not be completed R the permit is for one hundred dollars SEWER SANITARY SIORMEA 200F7 Date Remi til �O WATER HEATER W/VEM/EL[CTR ENERGYFEE Y N 3100)mless.) I certifythat In the perfounceoflhe work forwhich this permit is Issued, m WATERSYSTEM/TREATING I shall not employ any p n In any nunner n ss to beco aubject to the Workers Cggp)n..if. woof Callf9Tnia. Data "L'/— PAID Appllant_ Date Recei IN NEW RESIDENTIAL PLMB. SQ}T. NOT[CET PLICA If, alfa ung this Certlfiat of Exemption; you should become subject to el eri Compensation proAsImis of the Labor TOTAL: G Code, you ,wet forthwith comply with such provisions or this permit shall be doomed revoked.6 CONSTRUCTION LENDING AGENCY SEISMIC FEE I hereby affirm that there is a construction lending agency forthe perform ance of the work for which this permit is Issued (Sec. 3097, Civ. C.) Lender. Name bond.e.Addtess I certllylhatl have reacithisapplicatlonand siatethatthe above information Is correct. Iagree to comply with all city and county ordinances and nate laws TOTAL: ELECTRIC FEE L PLUMBING FEE QTY. MECHANICAL PERMIT FEE MECHANICAL FEE ` PERMIT ISSUANCE - l -2s0 FEES PAID: relating to Wilding construction, and hereby auhortm representatives of this citytoenterupontheabove.mentioned property for impedlon purposes. (We) agree to ave, indemnify an d keep harmless the City of C.peAte. again, gabil ,isdgmew, as sand expenses which may In anywayamue - ALTERORADDTOMECH. - Date ReCeiptif AIR HANDLING UNIT (TO 10,000 CFM) SUBTOTAL: 'Ftest In consequence of the granting of this permit AIR FIANDLING INR (OVER I0,000CFM) CONSTRUCTION TAX core of /Contractor Date FXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE lltheap ant orfuNre Wilding occupant store or handle 1,mardous l as define by/M Cupertino Municipal Code, Chapter 9.12 and the Health and Safety Code Section 25532(a)I MY.r Will applicant or Wilding occupant use equipment or devices HEATING UNIT(TO 100,000 BTU),Date Recei tNla EA HEATING UNIT (OVER 100,000 BTU) TOTAL: 1 ( VENTILATION FAN (SINGLE RESID) 2a� ISSUANCE DATE which emit hard rdous air mntarrira rats as defined by the Bay Area Air Quality Management Dislrid7 Yee nn No have read the ],.[,Mous materials requirements under Chapter 6.95 of he California Health & Safety Code, SeWdWm 25505, 25533 and 25534. 1 understand that if the ilding does not corrently have a tenant, that It is my PARD !'A� ) p ' '•-{ G'�9� 0C; BOILER -COMP OHPOR 100,(300 BTU) BOILER-COMP(OVER 100,000 BN) NEW RESIDENTIAL MECH SQ.FT rsponsibilily ion Ily the occupant of the requirements which moat be met o oWuance allAifl ofOttvpancy, VAurorauthodm Date TOTAL:ISSUED I. s - OFFICE COPY