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21841APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY Building Project Identification Building Addresa: PERMIT NO. 21841 S Ld (S d 976 /�j CITY OF CUPERTINO-BUILDING DIVISION APPLICATION / PERMIT A A A Contractor's Name: LIc. No. UIBLDING-ELECTRICALPLUMBING-MFGHANICAL CATEGORY CO OL s Architect/a'. Lie. No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INF PERMIT ISSUANCE ❑ ❑ ❑ Address: LICENSED CON ACTOR'S DECLARATION underprosiand of Chapter 9(mmmmc- I Wreby oodommthat l Division Ingweh5ectun 7000).f daffect. (the Buslmasand Pro(esslorasCade, and my license Is in fuB force and affect. MPLIANCFSRESIDENfTAL PANELS ]OB DESCRIPTION License Class Date ractor CoContnt — UP TO 200 ANIPS 201-1000AMPS ARCHITECTS DECLARATION I understand my planes shall be used as public records. OVER 1000 AMPS SQ. FT. FLOOR AREA S/SQ. FT. SIGNS ELECTRICAL Licensed Professional OWNER -BUILDER DECLARATION I hamby. lrm that I am exempt frumthe Contractors License Law for the following reason.(Sadhm 7031.5,Businesn and Professions Code: Any city or county which reqrn ula permit to construct, alter, Improve, demolish, orrepair any structure prior to its Issuance, also requires the applicant forsuch permit to file a signed statement that he is licensed pursuant to the prevbiow of the Contractor's License Law (Chapter 9 (commencing with Section 7000)of Divi- .ion 3 ofthe Business and Pnefenlo. Code) or that he la exempt therefromand the basis for the alleged exemption. Any violation of Section 70315 by any appliont fora permit subjectathe applicant to a civil penalty of not more than five hundred dollars %500). ❑ 1, as owee r of property, or my employewith wage as their wk SPECIAL CBtCU1T/MISC TEMP. METER OR POLE INST. [OWER DEVICES SWIMMING IDOL ELECTRIC VALUATION J OUILEISSWITCHFSFTXTURFS NEW RISIDENTIAL ELFfTR FI. SQ.Fr. - TYPE CONSTRUCTION compcnaaHon, will do the work and thexrocture Is not Intended or offered for vie (Sec. 7044" Busbrss and Profeas mu Code: The Contractor's License law does not apply to an owner of properly who Wilds or Improve thereon, and who does such work himself or through his own employees, provided that such OCG GROIII' RFS. UNITS improvements arena intended proffered fwmle. If, however,thebullding w improvement bsold withinore ye...fcampletlon,the mvner-builderwfll have TOTAL: the rdenofpmvingthathedid notbuedorlmprowforpurposeofsals,). I, as owner of the property, am exclusively contracting with licensedPERMIT contractors to construct the project (Sec. 7044 Businea and Professions Code: QTY, PLUMBING PERMIT FEE ISSUANCE PLOOD7ANE APN The Contractor's License law don not apply to an owner of property who Wilds or Improves n thereon, and who contracts for such pgojes with a cCtd) licensed pursuant to the Contractor's License Law. Kexempt under Sec B 6 P C for this mason ALTER -DRAIN k VENT -WATER (Er,) BACK FLOW PROTECT. DEVICE FEE SUMMARY Owner ! - Date ORmthatKMAN COMPENSATION DECLARATION ❑I hereby affirm that I have ate of consent to ora DRAINS FLOOR ROOF, AREA, COND. SANITARY Y N RFCEIT g FDnURFS PER TRAP SCIiOOL TAX Y N_ op theure, ceNBcateo(WorkersCompenaatlonlnauranawacertifled copy thereo((Sec. o Insurance 3800, lab CJ Policyan RECEB'r N GAS EA. SYSTEM -1 ING4 OUTLETS PARK FEE Y N Coy CcrtfOed copy b herebyfurnished.thecity ❑ Certified copy is filedhere y city impetlion division. GAS IA. SYSTEM- EM -OVER CREASE/INDUSIRL WASTE INTERCEPTOR BUILDING FEES PLANCHECKFEE G ETRAP CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATIONINSURANCESEWERSANUARYSTORM Unot Wm hissection need ncopleted lithe permit is (Drone hundred dollars (S100)orlceJ in permRis fused, [certify thatoy an person 1 shall not employ any person In any manner so a to became subject to the dumperhavdvk so as to become pca Com�nsatlon lawsof California. Date Applicant Certificate ofExemption, NOTICEco PAID Date Recei t# EA 2WF7, WATER HEATER W/VENT/EIECTR ENERGYFEE Y N — PAID Date Reeei tN WATER SYSTEM/TREATING NEW RESIDENTIAL PLMB. SQFT. e, ubiCAtothe oricmaklom a should become subject it the Workers' Compensation n provbfo. of the tabor of the Cada you must forthwith comply with such provisions orchis permit shall dee deemed revokN. TOTAL: BUILDING •E TOTAL: CONSTRUCTION LENDING AGENCY w there i a co®troction io (Soc. agenry for the peAorm 1 hereby work once of the work for which this permit is issued ($m. 3097, Civ. CJ SEISMIC FEE ELECTRIC FEE Lander' N. Lender's Address T cenlfythat I have mad this application and satethat theabowinfomatlon iscometl agree to comply with all city and countyordinancesand state laws relating tobuildingcorsWctlon, and herebyauthorize representatives ofthis city to enter upon the above-mentioned property fee inspection purpose. (We) agree to save, indemnify and keep harmless the City of Cupertino againstllab les, pdgments,costsand expenses which may In anywayaccrue agairui s City In mWoo of the granting of this rmR. QTY. MECHANICAL PERMIT FEE PERMITISSUANCE PLUMBING FEE MECHANICAL FEE FEES _ L(AID: ALTERORADDTOMFLH. AIR HANDLING UNIT TIO 10,000CFM) Date Receipt SUBTOTAL: - AIR HANDLING DnnT (ovFx to,BBoceM) CONSTRUCTION TAX �`pill/ln ,L` �.!/�C'r YDate Sig. ppecaAntb//c—olnt�ra-n`o�r HAZARDOUS MATERIALS DISCLOSURE E%HAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID: HEATING UNIT (TO 100,000 BTU) Will the applicant or future building occupant store or handle hazardous mxedal a de0nnd by the Cupertino Municipal Code, Chapter 9.1Z and the Date RCOeI tic Health and Safety Code�+. -S�ection 25532(.)7 ❑ Yes u No HEATING UNIT (OVER 100,000 BTU) Tq L: , Will the applicant or future building occupant use equipment or devices which emit havandom air contaminants as dented by the Bay Area Air Quality Management District? PYea he 1❑rZo ardfet m ode, Se requirem05,2553and 25545.95 of h Health the California Health k Safety Code, Sections 75505, 25533 and 25534. I understands llt the building does not cvdr.tly have a tenant, that cis my nes; 1 to notifythew panto( the requirements which most be nrt VENTILATION FAN (SINGLE RESID) ISSU 'DATE A �aa� r•Ia fs' $ aL t/s/ /N,L`1 {y� yiBtt�1Q BOILER-COMP(31OR IMOIX) BTU) BOILER -COMP (OVW2I W,000 BTU) NEW RESIDENTIAL MECH. SQ.F7 prior nceof a Certs eofOcrupancy. uthoT6rd agent Data 7OTA L: ISSUED BY: OFFICE COPY