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21517 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY B.11I Project Identification PERNITNO. Building Address: - 21517 iz� 7­7- O/Z ,xr me. one. A A OC CITY OF CUPERTINO-BUILDING DIVISION can aor'aNam: Lie.No APPLICATION / PERMIT C BUILDING-ELECTRICA4ML BING-MECHAMCAL CATEGORY CONTROL N Archltea/Engineer. e _ LIc.No: TY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: PERMIT ISSUANCE ❑ ❑ LICENSED CONTRACTOR'S DECLARATION herebyaffirmthat lamdder provisions ofChapter 9 APPLIANCFSRESIDEM7AL JOB DESCRIPTION IngwithSection7000)0(Dlvisd=3 afthe BusinessandProfessionsCodie,and my 11¢nse Is Info land dfeR. r PANELS �7 / License Gla»/�/ Lie.p G S d /`t�� Z.XO �C/` Date_¢2 1/ Cont_tUP TO 2DDAMPS 9ARCH ITECI'SDE AfJO. 201-1000AMPS 7. I understand rrry plata shallbs used as public records OVER TODD AMPS SQ.FT.FLOOR AREA S/SQ.Fr. O Licensed Professlorsl SIGNS PECIA ELECTRICAL OWNER-BUILDER DECLARATION SPECIAL CIRCIIT/MISC 1.., Thereby afflnnthatlam exempttrain the Contractor's License Law for the 07.21—� following mason(Section 70315,Businessand Profemlon.Code:Any city or TEMP METER OR POLE INST. q4muntywhich requlresa pemuttommtruct,alter,improve,demolish,orrepalr (S s anystmcture prior to its Issuance,alnorequiresthe applicant forsuch perMtto POWER DEVICES E c Ella a signed statement that he is licensed pursuant to the prostiloru of the Contractor.License Law tChiiImr9(carromming with Seaton 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION 111...... O slon3oit's Business and ProfessionsCode)orthat bels exempt therefromand Sm S the basinforthe alleg d exemption. Any violation of Section 70312 by any applicant for a permit subjectsthe applicant to a civil penalty of not mOUILETSSWITCIffSFl)ITlIRES ore than l� lid 6 , C6 flue hundred dollars($500. NEWRFSIDENTIALELECTR SQFI. STORIES TYPE CONSTRUCTION 1,as owner of the property,or my employees with wages u their sole rompensatlon,wRl dothe work and thestrocturc b not intended or offend for 7p Sc.It Bfl)d ssand Pians tons Code:The Contractors Lkmeelaw $ does not apply to an owner of property who Wilds or improves thereon,and $^ who doessuch worklameelforthrough hbownemployees,provided that such OCC.GROUIa RES,UNITS Improvements are not Intended oroffered for sale.If,however,the building or TOTAL: 4 Improvement esoldwithinoneyearofcompla3aM theowner-bul ierwill have tIgtu rdanofpromnglhat hedidno Wudorimprovemrpurposeofwle.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN M L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE mats&..to roretruct the project(Sec.7044,Business and Professions Code: The Contractor's License Taw does not apply to an owner of property who ALTER-DRAIN& -W TER(EA) Wilds or Improves thereon, and who contracts for such p5ojects with a FEE SUMMARY c?,gmtor(s)hcened pursuant to the Contractor'.License Law. BACK FLOW PR T. I_I I am exempt under Sec. B&P C for this reason OUTSIDE FEES DRAINSFLOOK ROOF,ARCA, SANITARY Y_ N_ Owner Dae RECEIPT N WOR KMAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCHOOLTA% Y_ N I ave a certificate of cement to self-Insure,o RECEIPT N �Icate of Workers Compensatlonlnsunnceoracertifbd ropy thereof(Sec. CAS EA.SYSTEM-1 ETS PARKFEE Y N 500,Tab CJ RECEIPT M rev 1'ollry p ified copy W hercbyturnbad' GAS EA.SYSTIMf OVER BUILDING DIVISION FIBS Com CertGREASE/INDUSIRL WASTE I PLANCHECK FEE ' �Certified copy bfiled with the citylnspactlon division. CERTIFICATE OF E0(EMP ION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWER-SANHARY-STORM EA.200FT. DRIC Remi I# (I"Immarn reed red be completed Bibs permit is foram hundred dollarsA. (51(0)orless) WATER HEATER W/VENT/dECTR ENERGY FEE Y_ N_ I certifythat in the performance of the work for which this permit is issued, I shall not employ an/person In any manner a as to become subject to the WATER SYSTEM/TREATING Workers Compcmationlawaof CalRomla. Date PAID O Z Applicant NEW RESIDLNTIi Date Revel t# Z O NOTICE TO APPLICANT:IE after maFdng this Certificate of Exemption,you F W a h.1dbecomesubpdt.the W.r .'Compe.tion provlalonsofthe Labor TOTAL: Code,you must forthwith complywlthauchprovielovorthis permit shallbe BUILDING a deemed revokedCONSTRUC ION LENDING AGENCY SEISMIC FEE 110 1 G I berebyaftlrmu4 thahem lata consuctton ismilegagency forthe perform ELECTRIC FEE Z arw of the work for which this permit b Issued(Sec.3097,Civ.C.) TOTAL 02 Lenders Name PLUMBING FEE I— Lender's Address QTY. MECHANICAL PERMIT FEE O W i curtlyNail havereadthb appbcaRongnd state that theabovelnformation MECHANICAL FEE IL 01 Iscorroct.I agree to comply with al city and county ordinances and state laws PERMIT ISSUANCE FEES PAID: lJ� relating to building construction,and hembyauthodze representatives,of thin city to enter upon the aboecmentioned property for inspection purposes. ALTERORADDTOMECH. DatC Receipt# (We)agree to save,indemnify an d Fiwp harmless the City of Cupertino gat Judgments,costs and e} which may in an way accrue AIR HANDLING UNIT 10,000 CFM) against g pen.ea y y y SUBTOTAL: against said City in cons epic.of the granting of this permit. CONSTRUCTION TAX AIA HANDLING UNIT(OVER tBLOOD CFM) Signature of Applicant/Contractor Date EKHAUS'r HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the a ppllcant or future building meu pant atom or hand to hazardous HEATING UNIT(TO 100,000 BTU) Date Recej t# material as defined by the Cupertino Mu mapal Code,Chapter 9.1Z and the I health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,00)BTU) TOTAL: a� ❑ Yea M No Will the applicant or future building occupant use equipmrat or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE which emit hezandom air conta minanb as defined by the Bay Area Air RAM, ' Quality Management District? BOILER-COMP DIP OR 100,000 BTU) B_ Yes E—]No have read the bazarrdiowmaterialsrequlmmcnbunder Chapter6.95ot BOILER.COMP(OVER 100,000 BTU) 1[]Q(� the Cali(ornW licalth&SafetyCode,Sealons 25505,25533and 25534.1 p ru; 7"s$O$11 undersWndthat lithe building does notcurrently have a tenant,that it bey NEIN RESIDENTIAL MECH. SQ.rT 1M"` prix to bllitytonfa notifythe otthe uircmeniswhkh mustW met psponsi uance stay thea f e OwIt, t Date ISSUF:DeY:�J CI[3Y�cuw ME.+Q..v—�-�v TOTAL: OFFICE COPY ,- 15 ICA cNaw h uj Vj Q % CAL / � II ]tAo ,l = U Q 5J � V Y in lV I in o Vi N O QNv00 a N ZOO z I ' �yn 1 "p SN MA y rVs > • M TJ iJ 4' HLL TJX, 'ycc