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21031 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PERMIT NO. Building Address:a3I� V-� Wwo 21031 ner• 60VStz l) L-tl5 g6aTo3S CITYOF CUPERTINO-BUILDING DIVISION Contractor's Name: LIc.No: APPLICATION I PERMIT -1 peBUILDING-ELECTRICAL-PLUMBING-MECFIAMCAL CATEGORY CONTROL X Architect/Engimer. Lk,No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: PERMITISSUANCE Ib1 ❑ L] 1:1LICENSED CONTRACTOR'S DECLARATION L-Lf Ihereby ion7OOOatlamBon3oftheesinemaonaolChapter9de,and APPLIANCES-RESIDENTIAL JOB DESCRIPTION Ingweh Section force effeon3otthe Buslnessand ProfnslansCode,and my ����� a••a�,(J� license Isinfull force and c.# PANES License Cls® LICX Date Contndor ARCHITECPS DECLARATION 211.1000 AMPS ut0 Z I understand my plan shall be used as public records OVER 1000 F AMPS SQ. T.FLOOR AREA $/SQ.FT. O f Licensed Professional SIGNSELECTRICAL C� OWNER-BUILDER DECLARATION �+a ZF, Ihercm hereby lamexempt fromthe ContractoJe Llcenx Law to the SPECIALCIRCUIT/MISC foRowing reason.(Section 7071S,Businessand ProfessAny city orions Code:A O TEMP.MI=. OR POLE IN r countywhkh requireea pertNttoconstmct,alter,lmprove,demolish,orrepair a LtRT anystruturepdormlteissuance,a iso requires the applicant for such permit to POWER DEVICES r U file a signed statement that he e,Ikensed pursuant to the provisime,of the O q Contractors Llcerue Law(Chapter 9(mmrnendng with Section 7000)of Dlvi- �0 the beatthe BuslneeeaedPMession. Any violation fSecti 7031S Sromany SWIMMING POOL EL TRIC VALUATION <� the baste for the alleged exemption. Any vlolatlon o(Sectlon 7031563'any OUTLETSSWTTCHES �© O(.) applicant for a permit subjects the applicant to a civil Pemltyofnotrnoretlun 11 five hundred dollars($500). ' NEW FSI ENTIALE PO.FT. �n ❑I,as owner of the property,or my employees with wages as offered sole SfO1tlI5 TYPE CONSTRUCTION com(Sec.744,But doth.work and the structure V not intended or offered for O sale(Sec.7044,Buebiesa and Pro(mlorm Code:The Contractor's Llcerue Law $$ does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RES.UNITS who does such work himself crthrough his own employees,provided that such improvements are not Intended oroffered forsale.f(however,the W ildleg or TOTAL; improvement Is sold within oneyearofcompietion,the owner-builder will have hSeburdenof proving that he did notbulld or improve for purpose olsale.). QTY. PL I T " FEE FLOOD ZONE APN �Q"I,as owner of the property,am exclusively contracting with licensed ppRMCf ISSU E trachars to construct the project(Sec.7044,Business and Professions,Code: Contractor's License law does rout apply to an owner of property who ALTER-DRAM&VENT-WATER(EA) Wilds or improves thereon, contracts and who for such plojects with a cQIllr+dor(s)Ikensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY LJ I am exempt under Sec. B&P C for this reason DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N Owner Date - - RECEIPT ` WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N ❑T hereby affirm that I have o certificate of consent to opytherro (Sa RECEIPT N 380,Lab of Worken'ComperosOon Wunnceora certlfkd copythereof(Sec. GAS FA.SYSTEM-]MCA OUTLETS PARK FEE Y N Polis lab C.) Pollry X CAS F.A.SYSTEhf-OVER 4(EA) DING DI M Com any BUILDING DVISIONITBS Ceetified copy is hereby fu thsty e e city �cenuled copy is rake with mwpemon division. GREASE/INDUSfRL WASTE INTERCEPTOR PLANCHECK FEE CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID COMPENSATION INSURANCE SEWER-SANPTARY-STORM FA.200FT. Date ReccCi t# Uhlssedlon need ner W completed lithe permit is(atone hundred dollars ($]UO)oifyth WATER HEATER W/VENT/ELECTR ENERGY FEE Y N— I mat that o any pehe rson In ani tmannerhework f,as to this n subjrmitect ct tot e I shall not employ any person In any manner ao n to become subject to the O WATER SYSTEM/TREATING Workera'Compensation Gws o(Glifomla.Date PAID — Z NOTICE M Z Z NOTICE TO PLICANT:IQ after making this Certificate of Exemption,you NEW RESIDENTIAL PLM& SQFr. Date Recei t# Fshould become sulapa to the Workers'Compensatlan provision.of the Labor TOTAL: CC N Code,you must forthwith comply with such provisions or this pemdt shall be BUILDING cos W > dcenvol revoked. IL O CONSTRUCTION LENDING AGENCY SEISMIC FEE 4 O I hereby affirm that there is a construction lending agency for the perform ELECTRIC FEE Z ance of the workfor which this permit is lssued(Sec.3097,Cle.C.) TOTAL: U0 ].^dere Name PLUMBING FEE LL t- LendcraAdd.. QTY. MECHANICAL PERMIT FEE I MECHANICAL FEE OW Icenlfythat l have read this appliatlonand statethattheabove Information 1 fsearrect.7 agreetocomplywith all cityand countyordlearcesand statelaws PERMIT ISSUANCE FEES PAID: W relating to building construction,and hereby authorize representatives of this F Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADOTOMECH. Dale ROeei t# — (We)agree to save,indemnify an d keep harmless the City of Cu penin P against llablitim,judgments,rolesand expenses which may In any way amue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: agXlnst said City in consequence of the goov-g of this Extend, AIRIiANDLINGUMT(0VFRI0,000CFMI CONSTRUCTION TAX igns Applicant/Contractor Date EXHAUST HOOD(W/DUcn CONSTRUCTION TAX PAID: HAZARDOUS "RIALS DISCLOSURE Willtheappllant or future building occupant storeor handle hasardous HEATING UNIT(TO 100,000 BTU) mDate Recei t# aterial as dented by the Cupertino Municipal Cade,Chapter 9.12 and the Health and Safety Cade Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: 1 l F1 Yea No Will the applicant or lure bulldingoccupant eseequlpmentordeAcea VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE which emit hares Mous air contaminants as defined by the Bay Area Air Quality Management D❑lslrid2 BOILER-COMP OHP OR 100,OM BTU) 4 Yes d No have read the hazy oua rtuleriab rcqulrcm.n6 under Chapter 6.95 of BOILER-COMP(OVER100,000 BTU) the Wlifomla health&Safety Coda Sections 25505,25533and 25534.I PAID understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT responsibility,to notify the occupant of the requirements which must be met SEP T-e p prior to Lssuance of a Certificate of OccuS pancy. I A� 1990 Owner or authorised agent Date 13SUEDIi`Ar vx7' TOTAL: OFFICE COPY