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21044 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PERhRTNO, Building Address: 21044 /7 E� secs area: A A /LL�3 APV$Gi �'- CITY OF CUPERTINO-BUILDING DIVISION Contractor's Name: .,i• Lic.N. APPLICATION / PERMIT S-e V7, 119 U Toth CUA>I lZ BU LDINGELECTR CA4PLUMBINGMEC AN CAL CATECARY CONTROL X :trchited/Engineer. Lic.No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: PERbRTISSUANCE ❑ ❑ ❑ LICENSED CONTRAROr pr DECLARATION I hereby affirm that)Division ofthe erprovand Pro Cbapter9de,a;d c APPLIANCFSRFSIDENML JOBDESCRQ'TION Ing with Sedan force of Divfect. fthe Buslnnsand Pro/neloreC�e,a�d my license is In full force and c.# PANELS License Chas Lk.M 3. Data Contractor UP TO 2DO ANTS �}T�T� UU 10 1��AS KyL I I ARCHITECTS DECLARATION 201-1000 AMPS � rs 7� I understand my plans shall be used as public recdrds OVER 1000 AMPS SQ.Fr.FLOOR AREA S/SQ.F r.' I�U Licensed Professional i ,- SIGNSELECTRICAL 6 m OWNER-BUILDER DECLAHATION- 7 Iherebyarm that lamexempt fromthe Coritr am- Llrenx Law fwthe ���LCIXCUIT/M1SC ffi oo following reason.(Section 70315,Bualness and Prolessbna Cade:Any dty or OZF.f� TEMP.METER OR POLE INST. F� countywhkh requbnape tocowtruct,settee,Improve,dennlbh,or.pair q .-I anystructure prlorta its ance,aleo requlresthe applicant(wauch pU tto y 4n�y V fl4 a signed staterrent t t he'h Iloenaed pursuant to the prowl1ss'lore of the POWER DEVICES �p?5$.Om Contractors License Law Tae,erg(mmmendngwith'SettWn7000)ofDivi- I:,K05 elon3of the Businessand 11��ooffessiom Coi.e)orthat heuexempttAerefromand `fM1NG POOL ELECTRIC VALUATION a^Sn" the bash for the alleged ePxmprtion. Any Wolatlon of .Mon Jm15 by any - re than OUILETSWR STCIiESFIXTlJRES 000-- �r5, ¢� appllcant(ora perMtaubjects lM1eapplkanitoadvll penaltyof ofnn p, Ove hundred dollars(5500). f NEW RFSIDI7JTIAL ELECTR �.. �I,as owner o(the property;pr mye ployen with wages stheG Ie �'�' SIOWGS 7Y1'E CONSTRUCTION �ZQ mmpcvatlon,w111dathe work anTl tAiswctvre boot intended r,o(feie 5 fffY❑ sak(Sec.706y eualr�eu and Profe.f�.lom Cade:Tse Contra is (cense Law j$ does not apply to en owner of property who buil or 1 rcon,and c- whodoessuch workhimselforthrwgh hisowne 1 -e s• 1 thaleach OCC.GROUT' RFS.DhTI'$ improvemenbare not Wended m cdf, to ut fh�wev,the uildingor TOTAL: Improvernamissold withNoneyearofc 1 N eovener-builderwlilhave Qtr Jgr not proving that he did not bull Isop vefnpurposnolsak.). QTY. PLUMBING PERMIT FEE FLOODZVNE APN ]ll(�y�'-r,as owner of the property,am ex Ively trading with licensed ppRISSIIANCE don to construct the project(Sec.7 Business and Professions Code: Contractor's License Law don rad apply to an owner of property who ALTER-DRAIN&VENT-WATER[EA) builds or improves thereon, and who contracts for such plojects with a og0.t{actor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT. FEE SUMMARY LI I am exempt under Sec. B &P C for this reason Ower Date DRAINS FLOOR ROOF,AREA,COND, SANITARY Y N— ftELEfIT R WORK MAN COMPENSATION DECLARATION FO(717RES-PER TRAP SCHOOL TAX Y N 01 hereby affirmorkem that p have o lr ur ate of consent to spytheure,ora RECEIPT It wrtiflrab C.) rken'Campemalion Wuranra oracertifled copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS Policyab C.) PARK FEE y N Policy R It CamnY GAS EA.SYSTEMAVER<(EA) BUILDING DIV ISION—FEESCertified copy b hereby tume city �Certlfled copy b(fled with the ty Inspection ddivision. GREASEANDUSERL WASTE INTERCEPTOR PLANCHECK FEE CERTIFlGIE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWER-SANITARYEA 20OFT Date Recef t# (fhb section need not completed((the pert b toucan hundred dollars Iwmrti (5100) lese.)fythat in the performance o(the work for which thle permit is Issued, HEATER W/ u , VENT/FI IN ENERGYFEE Y N— I shall net employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING C' ,Warkers'Compensatkm Lxwsof Callfarnb.Data PAID PP NEW RLSTDENTIAL PLMB. .FT. Date Remi t# Z O NOTICE TO APPLICANT:If,after ma king this CeAfflate of Exemption,you —SQ .FT. become subject to the Workers'Compensation provisions of the Labor TOTAL: CCN Code,you=at forthwith comply with such provisions orthb permit shall be D deemed revoked. BUILDING FEE .CDP dCONSTRUCTION LENDING AGENCY SEISMIC FEE L I hereby affirm that them b a construction lending agency forthe perform : ELECTRIC FEE Z ance ofthe worklorwhlchthb b permitLavred(Sec.3097,CIv.C.) TOTAL U O Lenders Name PLUMBING FEE IL h Iender'.Aaaress QTY. MECHANICAL PERMIT FEE MECHANICAL FEE O W Imnl/ythat l have read thbappliwtion and statethatthe above information 6 iscorrect.I agree to comply with all city and county ordinances and slate laws PERMIT ISSUANCE FEES PAID: >. W relating to building construction,and hereby authorlu representatives ofthis I— Z city to enter upon the above-mr.tkned property for inspection purposes. ALTER OR ADD TO MECH. — (We)agree to save,indemni/y an d keep harmless the City of Cupertino Date Receiptp against liabilities jrdgmenb,coetaand expe awMch may inanywaee accru AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: against aald 91 nsryue fthe ling a this permit. AIR HANDLING UNIT(OVER 10,(00 CFM) CONSTRUCTIONTAX SmtureofAplicanl/Contract , Ex]-uusrHOGG(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISC OSURE Will the applicant or future building occupant store or handle hacardous HEATING UNIT(70 100,000 BTU) Date Rceef 1# naIrrial as defined by the Cupertino Municipal Code,Chapter 9.17,and the I❑t yes Safety Cada SSelction 25532U)? HEATING UNIT(OVER 10,000 BTU) TOTAL: Will the applicant or rotate building occupant useequlpment orcievices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE -� which emit havrdousafr contaminants.,defined bythe Bay Area Air _ Quality Management District? BOILER-COMP OHP OR IDG DM BTU) 4 Yesn No havr read the hav ous nuterials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) ��n® the Califs 1.11nith&Safety Code,Sdiom25505,75533and75534. 1 7 understand that ifthe building does not currently have a tenant,that it b my NEW RESIDENTIAL MECH. SQ.F7. rnponsibllitytondilytheoccupantofthe quirements which must emet prior to issu o CertificaI fOccuv my y f'/r�9e EP 1 '� iy90 Owner or authonmd agent /r )(ata, , TOTAL: ISSUEDBY: I �: 7il'T OFFICE COPY