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21727 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY ulldln f Pen oIdemlflc llon PMITNO. Bonding ABddmas : Lor 3 u FR .1 21727 era aces: one A A /L C) f//l CITY OF CUPERTINO-BUILDING DIVISION Conuacto:aNanw, Lm.No: APPLICATION I PERMIT — / / CATTZORY CONTROL A,chitet/Engineer: - LI,,No: eU1LDINGELECTR(CALPLUMBINGMECHANICAL Slc/V L GO.vI ELECTRIC PERMIT FEE BUILDING PERMIT INFO QTY Add. PFRMITISSUANCE LICENSED CONTRACTOR'S DECLARATION IMmby a ffirmthatlamflc uduMerprovWomof Chaphr9(cummm APPLIANCES-RESIDENTIAL JOB DISCRB'ITON tngwith Secdon70W)of Divlslon3ofthe Buslnessand ProfelsdonsCude,and my license la In fuB f 2g d offect O p / PANELS License Class �- Date Contrador ARCHITECTS DECLARATION N)1-100 "PS NZ lundo.tandmyphrosMllbeuxdaspubllc.e a. OVERI"AMI5 SQ.Fr.FLOOR AREA S/SQ.FT. q@ O z Licensed Professional SIGNSELFGTRICAL / 6 OWNER-BUILDER DECLARATION SPECIALCIRCUT/MISC L., ] Iherebyaffirmthat l am exempt from the Contractor's License Law for the - Z O.. following reason.5etlon 7031.5,Business and Professions Code:Any city or OZI.. TEMP.METTR OR POLE INST. C`'�Ty O' county which requpriorrequires pauaAtomrotrouiresth applicant for to Q any structure prior to Its Lhat he is oho requires to the for such permit to file a signed aatesen,that M h licensed pursuant m the provisions of the ]OWER DEVICES Contradorl License law 3 (Cha er 9(mmmeci nn with Section 7D00 of Dlvl- res 8 w' ) SWIMMING IDOL FI.ECITIIC 110n3 ofthe Business and Professlom Code)cribs,he is exem thertfromand VALUATION p the basis for the alleged exemption. Any violation of Sion 70315 by anyOVILETSSWITCHFSFTX URES ;FJi' QQ applicant fora permit subjects n the applicant to a eivll penalty of not mothan / d, P' five hundred dollars(SSM. NEW RESIDENTIAL ELECTR ? � ,y,I,as owner of the pmperor my employees with wages as their sole SQ'T' STORIES TYPE CONSTRICTION compose tion,will dothe work and thestmoun h not Intended or offered for TF,O sale pec.7f K Busineas and Prolessioro Code:The Contractors License Law ('j, $ docs not apply to an owner of property who builds or improves therms,and - =s" who don such work hlmselfor through his own employees,provided that such OCC.GROUP RES.UNITS impmvementsamno intendedorofferedformle.ILhowever,thebuildingor TOTAL: improvement hsold withinoneyearofcamplebmthe caner-b WerwBl have to,,*rden of proving that hedld not build or improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE LJ L a owner of the property,am exclusively contracting with licensed FLOOD ZONE APN cvntrecton no mrutruct the project(Sec.70K Business and Professbss Code: PERMIT ISSUANCE Tia Contractor's License Law does nor apply to an owner of property who ALTER-DRAIN k VENT WATER(EA) Wilds or improves thereon, and who contrafor such ptotic a with a FEE SUMMARY �ttrractor exempt order Sntmthe Cgntrators Llanse Law. BACK FLOW PROTECT.DEVICE LJ I am exempt under Sec B k P C (or this n sect DRAINS.FLOOR ROOF,AREA,MND. SAMTARY Y N Owner Date RECEIPT N WORKMAN COMPUISATION DECLARATIONFD(TURE bySCIi00L TA% Y N ❑I hereby affirm that 1 have a certificate of consent to self-lnsun,,ora RPER — NN certificate ofWorlcrs Compensation Insurance ora certified copy (Se py the.fc. 3800,1.bC.) GAS EA.SYSTEM-1 INCA OIJILFI'S PARK FTS Y N IAillry N GAS EA.SYSTEM-OVER l(EA) RCCI]I'I'N Com env ll.,�.<4O qct FrL BUILDING DIVISION FIFES �Certlfied copy is henbyflished' GREASC/INDUSII2L WASEINTERCEPTOR PLANCHECKFEE Certified copy h filed with the city inspection division. CERTII'ICATB OF IAEMPTION FROM WORKERS' CRFA-SETRAP PAID COMPENSATION INSURANCE (Thiosetlonneed er.Mc.rn cpermuhfor one hundred dollenSEWER.SANITARY-STORM E.A.2(K)FT. Dabc Remipt (510 mrifyth WATER I IFATIRW/VENT'/FZECTR ENERCYFEE Y N Ialloy that in the person nceofthework so a tobocpermitctIs bused, 1 shall not employ any pawn In any manner so ss to become subject to the WATER SYSIFM/TREATING Workers'CompenssBon laws of Glifomh.Date PAID - z= N'OUCApplIcest NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t# Z O NOTICETOvaubjetiothe Rcr nt'Con. CertBlaneof Exemption,you skald became mbF t Io the Workers'Compevauon provuioro o(the Labor TOTAL: ~ N Code,you must forthwith comply with such provisions orthh permit shall W > deems revokd. PY P BUILDING FEE O d CONSTRUCTION LENDING AGENCY SEISMIC,rEE I hereby alfirm thatthem h a mnstrudlon lending agency for the perform ELECTRIC FEE Z Anaofthe vo,Mrwhich thiopored, ed(Sec.309'/,Civ.Q TOTAL: Q LL O lenders Name PLUMBING PLUMBING FEE LL F 1<nder,Addmaa / / era QTY. MECHANICAL PERMIT FEE MECHANICALFEE A O W d,iecttythatl to Apply io with state<hattbeabove information a hmrngt building condmctl n,alndty ebyauhoruze npnasand Gate taws PERMIT ISSUANCE FEE PAI : 'I } relating to building mtutrotlon,and Mnby authorize mpnsenhtives ofthh 2 (Q'15G (•.. Z city to enter upon the above-mentioned property for Wpection purposes. ALTERORADDTOMECH. V against ll bgrr a to save, a mode,cop and eskeep harmless the City of Cu peatino ate Receipt# jug pensee which may In any way aroe AIR HANDLING UNIT(TO 10,=CFM) SUBTOTAL: against said Cityy wquence of the granting of this permit. L NR HANDLING UNIT(OVER IO,WOCFM) CONSTRUCTION TAX 3 —� Signature of nppB cgn`rac, Date EXIMUS r uooD(w/DUC1) (�O ST UCTION TAX PAID: l HA7 RDOUSMATERIALSI SCLOSURE Iy -aL _�4s6 Will tM1c appllcwt or future building omsps store or handle hazardous IifATINGUMT(N100,000BTU) Date Reeel t# material as defined by the Cupertino Municipal Code,Chapter 9.17,and the p Ilalth and Safety CWP SetlonliS537(a)7 HEATINGUNIT(OVERl W,000BTU TOTAL: djs O ❑ Yea N No Willnheappllant orfutum Wildingoccupan,useequipmentordevims VENITLATION FAN(SINGLE RESID) ISSUANCE DATE. which eodt hazardous air mntamtuanta as defined by ted Bay Area Air (jaality Management District? BOILER-COMP(311P OR IW,ON BTU 4Ycs ❑❑Ng A haverndthe th&S fet Code,Se rcons M5ntsund and 25534. 1 of BOILER-COMP(OV[R 100,000BN) the Gltand hat if tth he building Cods,Mt1om 25505,A533 tenant that it 1 1991 nedpmtla ihtyI.f notify the don ofnot herequin,have atevhL ustithmy NEW RESIDENTIAL MECH. SQ.FT. FEB 4 napgtsibility to notify the ocevpant o/the mquimments which lust M trot prior to once WaCetlfic tc lOmspanry. p � • /2--—/pG/ � `° stn. assn ., Avner or out lull agent Date ISSUED BY:�• TOTAL: — OFFICE COPY