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21261 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY fluilding Project Identification PEILWTNO. Building Address: 21261 ,DT, neraNa ,r one: A A A fh // — CITY OF CUPERTIN&BUILDING DIVISION ,G O Comractur's Name: Lie.Na APPLICATION I PERMIT d �L •IBUILDING-ELEICTRICAL-PLUMBING-MECHANICAL CATEGORY CONTROL Architect/Englneee Lk.No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address PERMITISSUANCE ('2,00 ❑ LICENSED that CONTR under SOECI.ARATION Thereby,ofirm thatlamlkenredundesiremaonsof Chapter9(commmc- M[aLIANCFSRE5IDENTAL JOB DESCRIPTION mewl i Section 70W)of Dlvhlen3otthe Busina,sand Pm/esdonaCude,and my license lCla full force and dist. 1 PANELS D.tClass Lle s Date Contratlor ARCHITECTS DECLARATION 20I-1000AMP5 aOZ Iunderstand my plans.hall be used as public mcceda OVERIWOAMPS SQ.I7.FLOOR AREA S/SQ.FE O x 2 Limnxd Professional SIGNSELECTRICAL OWNER-BUILDER DECLARATION SI'ECALC[RCUIT/MISC 7 p,e7�f 3 I henbyafflrmthat I am exempt fmmthe Contnaori Llan:law fm the following reason.(Section 7015,Businessand Pmfessloru Code:Any dty or O tpppp'u9 county which roqulrcs a permlttoconstmct,alter,lmpmve,denolbh,orrepalr TFMP.MEIBORPOLEINST. y� < anyiructure prior to its koaance,also requlresthe applicant for such permit to POWER DEVICES J K U ilk a signed statement that he h licensed pursuant to the pmvlslom of the Contractor's License law(Chapter 9(mmmencing with Section 7001 of Divi-rofessSWP KING P70L ELECTR C VALUATION si..3ofth,B..I.e .a dPla.0ls ode)orthatheexe.ptth,efmmand I ER3^ •.1 the bast,for the alleged exemption. Any violation of Section 7015 by any 0[ITLETSSWITCI-IFSFIXTURES applicant fora permit subjects the applicant to a civil penalty ofnet moreNan r m five hundred dollars($500). NEW AESIDENDAL ELFGTR _ Ff_ �' C 2 6 A. owner of the property,or my employee with wages as their sole STORIES TYPE CONSTRUCTION c pp ..Hon,wllldothe work+ndtheatructurchnm Intended or offered for , \ /\\ }- ❑ n(See 7044,Business and Professions Code:The Contractor's License law does not apply to as owner of property who builds or Improve themonand LS� who does such work himself orthrough his own employees,provided that suchF \� Z_Jc(J✓ OCC.GROUP RES.UMTS Improvements are not Intended oroffered for sale.If,howevcq thebullding or '\ � � TOTAL: l Improvement h sold within nneyear nfmmpIdi.s,the ownr-b eudderwlll have the rdenofpmWng that hedld ro bulldorlmpmveforpurpoxofsale.). QTY. PLUMBI CPERMT V FEE v FLOOD ZDNE MN 1,as Donor tr the property,am exdnsiv si ess and ro essi licensed pFRMII ISSUANCE Cl TheconCo nrstoconstmt the w Iect does apply Business and of pro ons Code: V The Caor impro License ., does nal apply tct an owner p property who AMP4 -DRAIN 4 VENT-W AIFR(EA) Wild.t r Improve thereon, and who contracts for such p o)ect.with a l) FEE SUMMARY c,!J.t�adarW cmptdPursuant to the Contractor's License Law. BACKFLOW PROTECT.DEVICE �'f1 ' LJ 1 am exempt under Sec. B 6 P C for this reason IY ' DRAINS FIAOR,ROOF,AI4EA,C'OND; SANITARY Y_ N_ Owner Date RECEIPT WORKMAN COMPENSATION DECLARATION FIXTURESPPR MAP SCHOOLTAX Y_ N ❑1 hereby s01mn that I have a l certificate of consent to.pytnsurc,ora I ® Y' RECEPr M Milli,Lab of Worken'Compensatlon Wurance oracertifled copythemmf LSec. GAS Ey SYSTE.11-]WC4OUTLE75 PARK FEE Y_ N— Policy C.) t N Policy s RECEGAS G.SYSTEM-0VER 4(FA) DING DI s Com any BUILDING DIVISION PEES ❑Cetlfled copy It heed with the GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE ❑CcrtlRed copy b flied with the city inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' GREA-SE TRAP PAID COMPENSATION INSURANCE SEWER-SANppARY-STORM EA MFT. Date Remi t# (1'hbsetllon need cad bo complied If the permit h(Drone hundred dollars 3101llorless.) WATER HEATER W/VENT/E].FGTR ENERGY FEE Y N I mnify that N the performance of the work for which this permit is Issued, I shall not employ any person In any manner n as to become subject to the WATTR SYSITM/TREATING Wor4cnm 'Capensatlon Laws of CsIlf...I.. Date PAID O Z Applicant NEW READFNTIAL PIMB. SQ.FT. Date Recei t# Z O NOTICETO MI'LICAM:If,after making t his Certificate of Exemption,you should become subject to the Workers'Compensation provisions of the Labor TOTAL: W Cade,you most forthwith comply with such provisions or this permit shall Ix LU � deemed BUILDIN FEE r revoked. a o CONSTRUCTION LENDING AGENCY SEISMIC FEE e2- + I hereby affirm that there b a construction lending agency for the perform ELECTRIC FEE 7 Z ance of the work for which this permit h hued 5,c.3097,Civ.C.) TOTAL: L OO Lander.Name PLUMBING FEE LL Lendcr:Addres. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE Icedifythatlhavemadthbapp"tlonaMmtethattheabovelnform.tion O W a rrcct.I.greotommply Wlthalldtyandmuntyordinancoand state laws PERMIT ISSUANCE FEES PAID: > y relating to building corutructlon and lumby authorle mpmsontatives ofthli I.— city to enter upon the aWvcmentlo edpropedy for inspect ion pit ALTERORADDTOMFGH. (We)agree to save,i emnl , o d keep h='esss City Cu portion Date Receipt# V against liabilities,pd cat; sande w/bkh mayl nywayattmr AIR HANDLING UNIT(TO tO,WO CFM) SUBTOTAL: against said 1 ce of dthl.po I. AIRHANDLING UNIT(OVER IO,WOCFM) CONSTRUCTION TAX 5 mtum of Applicant/Contractor 6ote EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZAR DOUS MATER PALS DISCLOSURE Will the applicant or future building otvpant atom or hand To hazardous HEATING UNIT(TO I W,WO BTU) Date RCCCI t# �� material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the - Health and Safety Code Section 25532(.)7 HEATING UNIT(OVER I W Odd BTI, TOTAL- ❑Yrs M No ��meee�oorr��``` Will the applicant or future building occupant use equipment or devices VEN"ELATION FAN(SINGLE REBID) GE DA'L'E which emit hazardous air cone mlnsnts as defined by the Bay Area Air Quality Management Dist rit7 BOILER-COMP CEI'OR 100,"BTU) 4 havYese Ir`T-1 No t havercadthe r,lth& nus Code,Se requirements IIS nbunder Chapter 6.95 of BOILER-ODMP(OVp21 W,000 BTU) the Calim�nd hat lith building lfety Code,Sections 25505,ve a t and 25534.1 undentand that iRhtheccupant of not herthe equirmnts which that it met NEW AFSIUFNTIAL MECI{. JQ.PT � responsibility to isuato notifyCertificate occupant ofpaory.requirements must be met prior to Lwuancc da Certificate o(Onvpanry. Owner or authorized agent Date TOTAL: ISSUED BY. OFFICE COPY