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21847 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification I PERMIT NO. Building Addrev: < to v, 21847 IEZ More: SUBMITTALAPPUCATION AIT: 1 to $ —0? CITY OF CUPERTINO-BUILDING DIVISION cantor''racante: Lic.No: APPLICATION IPERMIT 2 ZAi YN c= '- BUILDINGdECTRICALPLUMBINGMECF LAICAL CATEGORY CONTROL N Architect/Engineer. Lic.No: QTY ELECFRICPERMIT FEE BUILDING PERMIT INFO Addrea% N'19 O/' PEtMIr ISSUANCE ❑ ❑ ❑ LIm that ED CONTRACTOR'S DECLARATION Hereby tbatlamlkm3.fth.under provisions ndPmfehapter9(commenc- APIPLIANCFSREADENTIAL JOB DFSCRR?ION increeiSection 6m,anDlvfect. (theBminenand ProtesalonaCaae,and my liana Is In fuse fpm d effect. PANELS Llan.eC ass - m Lic p_!- I2�E{9 Date fl 1 _I_ComraRor 'TaiMI�rry ARCHITECTS DECLARATION 701-1000 AMPS I urairm and my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA E/�.FI. WLicensed Professional SIGN'SELECTRICAL 6 f OWNER-BUILDER DECLARATION SPFfL1LCIRCUIT/MISC i.., 7n Ihernbm yalOrlhaam t l exempt incentive Contractor's License law for the oo following reason.(Section 7011.5,Business and Professions Code:Any city or FaZF camtywhich requiresa permit tommami alter,improve,dernalbh,orespair IFAiP.MECEt OR POLE INST. 645�� anystruaure polar to its Wu a race,aka requ tom the a ppBesot for such permit to YK` file a signed statement that he Is licensed pursuant to the provlalors of the BOWER DEVICES Ow Contractor's License Law(Chapter 9(mmmencing with Section 7000)of Divi- SWIMMING Il)OLELECTRIC 30r" sloraoftheguslnessand Pro(eaaloa Ccde)orthat he b exempt therefromand VALUATION G the basis for the alleged exemption. Any violation of Section 70115 by my I AAi�l.s applicant for a permit subject the applicant to a civil penalty of net morethan OUTLEISSWI7CHESF[XTIIRFS l� oV r a¢J a five hundred dollars(5500). NEW RESIDENTIAL ELECTR I as owner of the SQFI. STOIUFS ❑, ewpzrty,ormyemtureisswithended r ffered for elrwk TITPE CONSTRUCTION' ]Q ask CScompo7t ZwBldoss,and rohathes Codi,: Cintended License Law a O ask l5ec.7616,Buainna and[hvfesslom Coate:The ContnctoYe License Law does not apply to m owner of property who builds or improves thereon,and OCC.GROUP RIS.UMTS C0.• whodossuch work himself orthrough Haman employees,provided that such Improvementsare not Intended oroffered for sak.IL however thebullding or TOTAL: m Improveent la sold within oncyearofcampletloo the owner-bullderwill have ihe4urden of proving that he dm not bund or Improve for purpose of cake). QTY. PLUMBING PERMIT FEE FIpp z,pN ApN LI L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE comracton to contmet the project(Sec.7044,Business and Professions Code: The Cont actor's Liceme Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA) Wilds or Improves themmn, and who contract for such piyjects with a m,,IIRRfraaor(.)Reamed pursuant to the Contractor.Lt...Law. FEE SUMMARY 151 am exempt under Sec. B k P C for this mason BACK FLOW PROTECT.DEVICE • Owner Date DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y_ N WORKMAN COMPENSATION DECLARATION RECEIPT N f_11 hereby affirm that I have a certiDate of consent to sell-In Lure,or a F'DaVRES PER TRAP SCHOOL TAX Y_ N_ certificate of Workers Compeouation Irsumnmora cedifled copythereof(Sec. RECEPr! 380,Lab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N Policy M RECENT if Com ny GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FRES �Cedifled copy bffledwtumecity1.b1 GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE ❑cemned ropy la rhea with the dry Inspection alwamn. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWER-SANTTARYSIORM FA 200£1. Date Recet t# Thor aecdon need not W completed i(the pnrtmt la(or oro hundred dollar (5100)dify that WATER HEATER W/VENT/ELECTR ENERGYFEE Y N Icedify that Nthe performance of the work forwNch this permit is cawed, — I shall not employ any person in any manner n n}}QQ bamme , mile WATER SYSI,EM/TRE).TING Workers'Compmti.nLawsof Califyr�is.Date_'4 I L PAID O Z Applicant %ArA g b XJF f/`F NEW RESIDENTIAL PLMB. SQ,FI', Date RCCei t# Z O N'OTICETO APPLICAN 1;U,after making this Certificate of Exemption,you should become sub),&to the Warken'Compensation provisions of the Labor TOTAL: WN Code,you most forthwith comply with such provision or this pemdt shall be > deemed revakcd. BUIL12ING FEE CSO CL ONSTRUCTION LENDING AGENCY SEISMIC FEE O I hereby alarm Cthat there is a conatructlon lending agency for the perform- 7 Z ance of the work for which this permit is Wood(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE O O lend``.Name PLUMBING FEE LL ~ LendersAddrom QTY. MECHANICAL PERMIT FEE O W Icertilythatl have read thisappBationand state thatmeamvelnumnatlon MECHANICAL FEE M Is mnect.l agree to comply with Ali city and county ordinance and date laws PERMIT ISSUANCE FEES PAID: >. Wrelating to building convuRlon,and hereby authorize representatives of this H Z city to enter upon the aWv nnvrtioned property for Inspection purposes. ALTER OR ADDTO MECH. V — (We)agree to ave,indemolly an d keep harmlen the City of Cupertino Date Receipt# against liabilities,judgments,costs a nd expenses which may in any way accrue AIR HA NDLING UNI'fro ID,000 CFM) agaitsam Ch I nugamaaf the un Mori. SUBTOTAL: R granting permit. AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX Sig sere a(Appllant/Contactor IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant orfutumbullding occupant storeor handle hazardous HEATING UMT(r0100,ODD BIIn Date Recei t# material as defined by the Cupertino Municipal Cade,Chapter 9.17,and the He❑ ❑ Yes elthand Safety Code, No Section 75525532(a? HEATING UNIT(OVER I00,000 BTU) TOTAL- Will the applicant or future Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE which emit havrdous air contaminants m defined by the Day Arca Air Quality Management District? BOILER-COMP OHP OR 100,0()BTU) ��� Yes F No hove rcadtheh r�r .0 ater.l rrequlremcnbunder Chapter G95of BOILER-COMP(OVEr 100,000 BTU) the California Health k Safety Code,Sections 25505,25533 and 25534. I understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. ';C0 ] 1891 responsibility to rally the occupant of the requirements which must be met b 4 prior to Lasuance of a Certificate of Occupancy. Owner or authodud agent Date ISSUED BY:� LUTA L: OFFICE COPY