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21009 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identlfiotlon PERMITNO. Building Address: 21009 (e N GU u u n sea asst: p e) Ue g 914SCIV-S - ?S CITY OF CUPERTINO-BUILDING DIVISION l� �O Contactors Name: Lic.No: APPLICATION / PERMIT l BUILDING-ELECTRICAL-PLUMBING-MECELkNICAL CATEGORY CONTROL M Architect/Engineer, Lie.Nex QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: PERMITISSUANCE c cr ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION I hereby affirm that l am licensed under provisions of Chapter9(comment APPLIANCESRFSIDENTIAL ]OB DESCRIPTION If reel infullforcta deffeon3ofthe Businessand ProfessloneCode,and my UP TO 2DO ANIPS license b In full form and effect. PANELS r f I- LlcenseCla® LIcY Date Contractor ARCHITECPS DECLARATION 201-10WA.MPS At QZ I understand my plans shall be used u public records. OVER1000AMPS SQ.FT.FLOOR AREA 9/SQ.FT. O Licensed Professional SIGNS ELFfTRICA G w - OWNER-BUILDER DECLARATION I herebydBmtthat lamexempt from the Contractor's License Lawforthe SPECIAL CIlZCUIT/M t following reason.(Section 7031.5,Business and ProfessionsCode:Any city or TEMP.M R POANST. _4t'� cmntywhichrequi apermitmmmtmd,alier,impmvgdemolbh,orrepalr anys[mctvre priorto its Issuance,also requlresthe applicant for uch permit to POWER DEVf Vfile a signed statement that he Is licensed pursuant to the provisions of the 3 u, Contractor's License Law(Chapter9(commencing with Section 7000)of Divi- SWIMMING WL ELECTV sion3 ofthe Business and Professions Code).rthat he is exeretherefroma rad VALUATION Sn S the basis for the alleged exemption. Any violation of Section 7011.5 by any xETS TCI B:S Eq applicantfora perent suci bjesthe applicant to a dvll peraity of ect moan than live ndred dollars(5500). R' AL TR SFT. STORIES TYPE CONSTRUCTION' I as owner of the property,or my employees with wages as their sole t�7¢ ca unsation,will dothe work,and the structure Is not Intended or offered for ��0 sale(Sec.7044,Business and Profeaslors Code:The Contractors License Law OR does not a pply to an owner of property who Wilda or Improves t hereon,and OCC.GROUT' RES.UNITSEE who doessuch work himseUortherugh bis own employees,provided that such Improvements are not intended oroffered forsale.If,hoveevep the Wilding or TOTAL: Improvement Issold within one yea rof completion,the owner-builderwill have t1lt¢urden of proving that he did nes Wild or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN Lj L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE contractors to mratrun the project(Sec.7044,Business and Professors Cade: Ile Contactor's License Iaw does not apply to an owner of property who ALTER-DRAIN&VENT-WATER ffNN Wilda or Improves thereon,and who contracts for such projects with a co dor(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY 1 11 am exempt under Sec. B&P C for this reason BAIX FLOW PROTECT.DEVICE OUTSIDE FEES DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_ . Owner Date - - RECQPT p N ORKMACOMPENSATION DECLAR TION FIXTURF$PER TRAP SCHOOL TAX Y_ N_ ❑1 hereby affirm that I have a certificate o!consent to self-Insure, ora RECE PT Y cedificate.fWorkeri C.mpersallonlrsunnce ora ceril(led copy themo((Sec. GAS FA.SYSTEM-1 INCA OUTLETS PARK FEE Y N 3800,lab C.) RECEBT p C.I'. Y GAS F.A.SYSTEM-OVER dIRA) BUILDING DIVISION FEES an ❑pCeyrtlfied copy Is hereby furnished. CREASE/INDUSML WASTE INTERCEPTOR PLANCHECKFEE ❑CcAifled copy Is filed with the city ImpeaHon drolalon. CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASE7RAP PAID COMPENSATION INSURANCE SEWER-SANTIAAY-STORM EA.700FT. Date Rccei t# (Thlssectlon need not be completed if the perent Is forone hundred dollaro 05100)ml..) WATER HEATER W/VEM/FLLCTR ENERGY FEE Y_ N_ I cerilftffi071' orof the wok for whlchthispermRlsiuued.I shallnon an mannereoWATER SYSTEM/TREATINGY PAID Wrke- fCalifomiaDateO npphamany:, Date Remi t#ZZNOTICE nter makingthIs Ccriiflote o(Excmption,You NEW RESIDENTIAL I'LMB. SQ.FT. Hshould become aubj¢t to the Workers'Compersation provIsiors of the Labor TOTAL: � W Cod,you must forthwith comply withsuch provlsimumthh,pemdtshallbe QUI NG ' I C j deemed revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE CL Ibeerbyaffrm that there is a construction lending agency for the perform- Torpl: ELECTRICFEE t M Z ante of the work for which this permit is Issued(Sec.3097,Civ.C.) PLUMBING PEE Vlender'.Na O me LL I- lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE IcertBy that l have read this application and state that the above information O W C. is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID: } relating to Wilding construction,and hereby authorize representatives ofthIs I'_ city to enter upon the abovccmention,d property for Inspection purposes. ALTER OR ADD TO MECH. (We)agree to cave,Indemnify an d keep harried.the City of Cu Perim. Date Receipt# V agai HUT, It cost s,Judgments, s and expenses which may inanywayaccmAI e R HANDLING UNIT(TO 10,"CFM) SUBTOTAL: ag is CC y in consequence of the granting of permit. CONSTRUCTION TAX �j AIR HANDLING UNIT(OVER 10,W0CIM) Slgnatvrc o(App cant/Contractor a—)� EXHAUST HOOD(W/DUCT)(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future Wilding occupant store or handle hazardous HEATING UNBT(T0100,000 BTU) Date Recei t# I materials.defined by the Cupertino Municipal Code,Chapter 9.1;and the health and Safety Code Sect' 32(a)7 HEATING UNIT(OVER 100,000 BTI. TOTAL: ❑ Yes o S1 Will the applicant or lawns building.eevpant use equipment ordevices VENTILATION FAN(SINGLE RESID) - ANCE DATE which cent hevrdm a air romaenrams as defined by the Bay Arca Air _ alality Management District? BOILER-COMP OHPOR 100,009 BTU) A? Yes 1�es� 4 vc y have read the hares smaterials requirements under Chapter 6.95 of BOILER.COMP(OVER 100,000 BTU) CaliforniaHealth&Safety CodeSections 25505, 33 and 25534.I Ofunderstand that building does not co4,have at � b my NEW RESIDENTIAL MECN. SQ.FT 1[ r s ,ibilit Door ify the of the requirements which must be met PJner Ora an .fa Certificate of Om pa racy. A Ar 01-17 p . tWR.cdagent Date TOTAL: ISSUED BY 0FFICE COPY