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21929 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES—VSE-BALL POINT PEN ONLY BuBuildingProject ilding Address: Idedrificalon_ - PERFR7 N0. X930 L�D. C�c � 21929 neva me: _ - A . f�11.zi'13L APPLICATION A 4 2 CITY OF CUPERTINO-BUILDINGDIVISION 1 � A meter's Name: ^ Lie.N.: APPLICATION I PERMIT a, ( TyQTS Q`1 R�-T S Lie BUILDING-ELECTRICA PLUMBING-MECHAMCAL CATEGORY CONTROL p ArcMtet/Engineer: No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: A-�� PERMITISSUANCE ❑ V1 ❑ ❑ LICENSED CONTRACTOR'S DECLARATION It...I hereby-(firm0)ofDthat I mlkm3.fth.under pcass.onaofmdomChapter 9(ro.rd.3 APPLIANCES-RESIDENTIAL JOB DESCRIPTION With Se tion fore and effect. Buslneseand Pro(enelanaC�de,and my D license is iafuB farm and effect PANELS License Class LM.r - Date Conhactoi UP TO 2DO , ARCHITECTS DECLARATION 301-10DOAMPS O Iundentand my Fit--hall be used as public remrds OVERI000AMPS SQ.FI.FLOOR AREAE�,IQ a z Licensed Pralesslorul SIGNS ELECTRICAL OZ 2,-6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC ❑❑❑ Iherebyaffi.that lamemerpt from the Contractor.License Law for the 1 following reason.(Section 7031.5,Buslnese and Profession-Code:Any city or pv� muntywhichrequiresapermlttomvtrut,alter,lmpmve,demolbh,orrepalr TEMP.METER ORPOLE INST. q a e-signed statement that he is licensed undo t to the provisions permit to ^�gO file a signed rtce..Lt that he(Chapter 9(com pursuant to the pro 7000) o! the (OWER DEVICES H E, sion3 Ofthe Liceme LawrofessCode)or tat with Section 70W)omand t, � elon3o(the Boatloads and Profs-sbro Code)orthat hely exempt Nere(romand - SWIMMING POOL ELECTRIC � VALUATION Y.' the bash Tenths alleged exemptbn. Any violation at SMion 70315 an �� applcant(ora permit-ubjectsthe appllemttoa dvil penalty of no[more than OUTLETS-SWITCHES-FIXTURES five hundred dolhn($500). ,. ❑I,as owner of the property,or my employees with wage-a their sole NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTTON 7a compeneation,wRldothe work,and theatrocturels notlnlended or offered for O sale(Sec.7046,Buslneea and Profemian-Code:The Contrarlors Llreme Law '� does not apply to an owner ofproperty who Wiida or improves there no,and .. , who does-uchwork himse8orthrmgh hleownemployees,,provided thatsuch OCC.GROIJP RES.UNITS improvementeare not Intended oraffered lor.ale.If,however,the Wilding or TOTAL: rmprovementbaoldwlthln oneyearo(campltion,theawner-bulWerwIII have t Nen olproving that he did not bund or bnprove for purpose otask.). QTY, PLUMBING PERMIT FEE u;as,owner o(the properly,am exclusively contracting with licensed - FLOOD,OD APN rontracton to corutmRthe Pro ject(SeC.7044,Businenand Professions Code: PERMIT ISSUANCE ' The Contnctor'e License Lw does not apply,to an owner of property who Wilda or Improves[hexon,and who centras- for such prajecis with a ALM-DRAIN VENT-WATER(EA) offetor(s)licensed pursuant to the ContraRorb License Law. FEE SUMMARY L.�I am exempt under Sec. B'&P C for this reason BACK�W PROTECT.DEVICE Owner Date DRAIN&FLOOR ROOF, COND. SANITARY Y_ N— WORKMAN COMPENSATION DECLARATION RECEIT# OW ❑1 hereby affirm that I have a certificate of consent to self-Insure,or a PIXTURF&PER TRAP SCHOOL TAX Y N certificate DI o(Workere Compensation Irsurmce or certBled mpythereof(Sec. RECEIPT a 3.I Lab CJ GAS FA.SYSTEM.1 INC4 OUTLETS PARK FEE Y N Polley# - RECEIPT if . Com any GAS d(E GAS-FA BUILDINGDIV Certified copy is hereby fumlahed. ]$IONFBES Certlied copy I-filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE CERTIFICATE OF EXEMPTION FROM WORKERS', GREASE TRAP PAID COMPENSATION INSURANCE ' IThle.ectioe.red not becompleted l(theperent laforoaehundred delta, SEWER-SANITARY-STORM EA.300FT. Date Recei t# '($100)orlth ENERGY FEE Y N lll-achatlntany Person many le mannrk(.,Whichad obecome subject WATER HEATER W/VENT/ELEC7R N- 1 stall not employ any person In any manner an as to become subject to the O Workera'CompenaaHan lawaol Cahfornla.Date WATER SYSTEM/TREATING � PAID Z Applicant Z 0 NOTTCETOAPPLICA .lf,aftermakingthb CeNflcateof FaempHon,you NEW RESIDENTIAL PLMB.abou:d become roviders,of the Labor SQFT. Date Recei t# ~ N Code,you mu at forthwith co ply with such providensation.or this pem,itshall be TOTAL: W > deemed revoked. BUIL IG FLE IL0 CONSTRUCTION LENDING AGENCY SEISMIC FEE Z I hereby affirmthat there is a construction lending agency far the perform- ELECTRIC FEE ... fthe..,it for which this permit is Issued(Sec.3097,Civ.C.) -TOTAL: LL O Lender.Name PLUMBING FEE LL I- Lender.fythel QTY. MECHANICAL PERMIT FEE MECHANICAL FEE O W mdl ythatl havereacithisappli atlonand�ate thattheabove in(ormaHm 1 scorret.I agreete,comply with all city and county ordinances and tate laws PERMIT ISSUANCE FEES PAID: F- (D relating to building construction,and hereby authomm representatives ofthis I" Z city to enter upon the Above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. V — (We)agree) save,indemnify a ep harmlea the City of Cupertlne Date Reeei t# against flab 14e,judgmenb,rostra ex see which may In a/n(Yy ay esus AIR HANDLING UMT(T010,000 CFM) SUBTOTAL: against. comae a ming of this permit! 14 1 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX Si nature of App cant/ContratorateI I EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) material as,defined by the Cupertino Municipal Code,Chapter 9AZ and the Date Reaei t# Is. and Safety Cod o 75533G)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: ❑Yes No Will the applicant c cure building occupant use equipment or devices VENTILATION FAN(SINGLE RESID)' ISSUAJNT^q)R�TE Which emit hazardous air contaminants,as defined by the Bay Area Air X-8riV1 l u�_allty Management Diyptt7 BOILER-COMP QHP OR 100,000 BTU) • q Q IT,Yea (�rJdI3No have read thehaz us,materials requirements under Chapter 6.95 of BOILER-COMP(OVER100,000 BTU) the California Health&Safety Code,Sections 25505,75533 and 35534.I t understand that!(the building do not corrently ,haveatenanL that It rs my NEW RESIDENTIAL MECH. SQ.IT. rnportibility to notify the occu ant (lherequlrementswhich..at be met dsI{y a-{(su..d- 9f� prior to • fa panty. 9aalAr V8}3 II'p . Owner or authorized agen Date - n . 'TOTAL: ISSUED Btu �J' - OFFICE COPY