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21862 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY ,. Building Pro«t Identification PERMITNO. Id' razw?7 rfie 4clL21862 ners amn: one: p ' 267— CITY OF CUPERTINOBUILDING DIVISION Zb -_q / Contract. Name: sae.N.: APPLICATION /PERMIT Z— C 1 ' red r BUILDING-ELECTRICAL-PLUMBINGMECHANICAL CATEGORY CONTROL N Archlten/Engineer. Llc.No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO BLOU Address: PERMITISSUANCE (NA ❑ ❑ El CONTRACTOR'S DECLARATION I� I hereby affirm that l am licensed under pmvislons ofChapter9(commmc- APPLIANCES-RESIDENTIAL JOBDF5CRI11ION Ingwllh Section 7000)of Divig e,n3ofthe Bminesaand Professions Code,and my license la in full force and effect. PANELS License CsssLle N Dae Contractor Ul!TO 2DO AMPS 201-1000 AMPS ARCHITECTS DECLARATION NO 2 I understand my pions shall be used u public records. OVER 11X10 AMTS SQ.FT.FL SQ.FT. O �'i Licensed Professional SIGNSELECTRICAL Q OWNER-BUILDER DECLARATION j Ihereby affirm thatI am exempt from the Contractor's License Law for the SI'ECIALCRCUIT/MISC following reason.(Section 7015,Business and Professions Code:Any city or O F TLMP.MECER OR POLE[NST. county cture requlroapermlttomwtwctiresth applicant to F 4j any swcture priorttatemoibbat he Is also rcgpursuant to the rovixior hpeof to ppyypR DEVICES V floe a algned ncens eLa that he t r9lic(commencing pursuant to the tion MO) of the Y�Ou, Contractor's Lkenselnd PC epter9(mmmenchathe eS mptthemfomaM OS slon3oflhe Buainessand Professions Code)orthat hebexempthere(romand SWIMMING IX70L ELECTRIC VALUATION yd•s Y the bass far the alleged exemption. Any vI.Ig an of Se tbn 7m IS by any O TILETSSW TCHFSA R RFS Y f/Q O G� applicant fora permlt subjects the applkanttoacivil perky of not mom than .J _ s fav=h)(ndred dolUn(550(). NEW RFSIDENTLAL ELECTA en as owner of the property, `�� STORIES TYPECONSTRUCTION persap perry,or my employees with wages r their sole C7Q men re wWdothe so.rotwork and the stmcturebn ontracded orofferedLaw cele(Sec.7044,B..bess and Professions Code:The Cantnctots Llcesue Law {�$$ does not apply to an owner of prupetywho Wlldsor improves thereon,and OCC.GROUP RES.UNITS E whodomauchwork himselforthrough his own employees,provided that such Improvements arc not intended oroffered for sale.If,however thebullding or TOTAL: improvement baoldwithln owyearofcomplctiomtheowner-buRderwill have th,*rden of proving that he did not Wild or improve for purpose ofsele.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN Lj L as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code: PERMIT ISSUANCE The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EM or Improve thereon,and who contra for such p�ojets with a cccc'ggqqBBBBffIf((I(act�ortrms)jBTcenxd p�uyrsusa,nrt to the Corm.doe.Licenu Law.Date BACK FLOW PROTECT.DEVICE FEE SUMMARY 1 B&P C for this reasonOUTSIDE FEES Ow er' - 1L{�f r^ DRAINS FLOOR,FLOORODF,AREA,COND. SANITARY N F9 • Y_RECT N g WORNAN COMPENSATION DECLARATION FD(TURES PER TRAP SCI IDOL TAA Y N 1 hereby affirm that I have a certlfiote of consent to self-Insure,ora RECEIPT N cetificeteofWorkesi Comp,..ti nlnsurarxem.certified ropy themof(Sec. GAS EA.SYSTEM-1 WCAOUTLETS PARK FEE Y N 3800,Lab Q RECEIPTN C. tl CAS M EA.SYSTE .OVER 4(EM BUILDING DIVISION FEES Com any ECertifxi copy Is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE Certified copy is filed with the city Inspection division. CERTIFICATE OF UEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCESEWER-SAM.I.ARY-610RM FA pBFI. Date Recei t# (rhlssection needot nbecompleted tithe permit b forons hundred dollars ($100)oricss.) WATTR HEATER W/VEM/EL[CTR ENERGY PEE Y_ N_ I certify that In the performance of the work forwhich this permit Is Swed, 1 shall not employ any person In any manner ro ns to bemnn wbject to IM WATER SYSTEM/TREATING Workers Compensation laws of C+Bfomla.Date PAID O Applicant Date Recei t# Z NEW RESIDENTIAL PLMB. SQFT. Z O NousNOfICE TO subjed APPLICANT If,after making om a Certificate is Exemption,you should become subject to the Workers'Compensation provisions of the Labor TOTAL: �) Code,you=at fort hwith comply with such proWions or this permit shall be BUILDING FEE _ U6 > deemed revoked. W _ CONSTRUCTION LENDING AGENCY SEISMIC FEE .SO R I hereby affirmthat there baconstrutlon lending agency for the perform TOTAL: ELECTRIC FEE 7 Z ance of the work for which this perent b bsued(See.3097,Civ.C.) O O landess Name PLUMBING FEE U. lender's Addrem QTY.I MECHANICAL PERMIT FEE MECHANICALFEE U lutlfythatlhavemadthbapplknlonandaatethattheab.veinformation O W isconect.I agree to comply with all city and county ordinances and gate laws PERMITISSUANCE FEES PAID: 1 reI.ti.gt.buildIrgcmvtmtlm,,..d Mrebyauthodzempreuntativeaofths I— N city to enterupon the above�mentlomci propertyforimpectionpurposes. ALTERORADDTOMECH. Z (We)agree to save,Indemnity an d keep harmless the City of Cupertino Date Retelpt# V against liabilities,Iudgments,cogs and expenses which may In anywayaceue AIRILANDWNCUNFF(TOl0,000CFM) SUBTOTAL: against+ ac' aonp+e of the gr.Qpng of permit. CONSTRUCTION TAX �/ AAHANDLNG MI(OVERIO,000CTI "A CONSTRUCTION TAX PAID: Sig of pp t/Contractar� Date EXHAUST HOOD HAZARDOUSMATERI LS DISCLOSURE HEATING UMT(T0100,000UN) WI the applicant or future building occupantgme or handle hazard... Date Retel t# material as defined by the Cupertino Municipal Code,Chapter 9.17,and the N Iiealth+nd Safty Code Setion25532(a)t HEATING UNIT(OVER 100,000 BM TOTAL: vX . Fly. , MN. Will the applicant or future building occvpantuse equipment mdevices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE which emit hazardous air contaminants as defined by the Bay Area Air • QualityMarwgementD'uttct7 BOILER-COMP DIIPQRl00,IX10BTU) PAID Yrs 2nus 6��1� nava read the haza7oua materials requirements under Chapter 6.95 of BOILER-COMP(OVFltIW,000BTU) the Glifomia Health&SafetyCode,Scc,imw SSQSM&13 and 25534.1 Cuu p 61991 sanderstandthatifthebuildingdoesnamrrentlyhaveatenanLthatltsmy NEWRESIDENTIALMECH. SQ.PT. ITNK pj responsibility to notify the occupant of the requirements which most be met prior to issuance of a Certificate ofOccupancy. CIb�Cupg�''�e Owner or authorized agent Date TOTAL: ISSUEDBY: OFFICE COPY