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21708 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY Building Project Identification LO —I PERMITNO. Building Address: \ "'lG5 1LtD C2ttGC, eT 9" n 21708 mer. came: one: ADATE— It C CITY OF CUPERTINO-BUILDING DIVISION •I ra"°'•NY APPLICATION I PERMIT BUTLDING-ELECTRICALaL BING-MECHANICAL CATEGORY CONTROL# Itect/� glmx �xty ` QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address PERMIT ISSUANCE LICENSED CONTRACTOR'S DECLARATION I hertby affirm that lam Bcrnsed underprovlslomo(Chaptcr9(03030303 APPLIANC6SRESIDENTIAL JOB DESCRIPTION Ingwlth Sectton7000)of Mi t.lon3ofthe Buslnessand PmfeW sCode,andmy lion:Isles"f. anddfe". �{ 9 PANELS SF �� License Class LICI I/3(l� / Dae Comrsctor UPTOWDAHM ARCHITECT'S DECLARATION MI-10DOAMPS rs0 7 I understand my plans shag be used as public recomla OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.Fr. O <<Z� Licensed Professional SIGNS ELECIIUCAL � �� `� <<re OWNER-BUILDER DECLARATION S (H- i..]i— Ihereby aRirmthat l am exempt from the Contractors License law for the S / 'Z O`�.. following mason.(Section 7031.5,Business and Professions Code:Any ctty or F<�s� county which req.Imsa permit to mnstrud,alter,lmpmv,demolbh,orrepalr I /�1��•.i'-� any structum prior to its court me,also requires the a ppllunt for such permit to POWER DEVICES "I 1 C c. file a signed statement that M b licensed pursuant to the provisions of the Contractor's License LAW(Chapter 9(commencing with Section 7000)of Divi- SWIhYR'Y F�O< sJon3ofthe Businnsand Professions Code)orthat he6vempt tM1ercfmmaM VALUATION •.t the Wats for the alleged exemption. Any violation of Section 7071.5 by any OU)LE.ISSW1TCHFS-FIX URFS < applicantudred dollars he applkant tot ctvll penslty of net nnre than (_+ Oo five hundred dollen he pr. '❑I,as owner of the property,or my empbyem with wages ao thalr sole NEW RESIDENTIAL ELEC7R �.IT. SI'OItIPS TYPE CONSTRUCTION 7C mmpensait will do the work and thestm"um V not intended or offered for ❑ sale(Sec.7044,Business and Professlons Code:The Contractors License Law 5$ duce nut apply to an owner of property who W lid.or Improves thereon,and - OCC.GROUT' RFS.UNITS who doca such work himself or through his own employees,provided that such improvements are notlntended oroffemd forsale.If,howcvcq the building of TOTAL: Improvement usold within oneyearofcompletlon,the owner-bullderwlll have thr4urdenof pmvingthat he did not build or improve forpuMme ofsale.). OTy, PLUMBING PERMIT FEE FLOOD ZONE APN u I,as owner of the property,am exclusively contracting Wlth—111—a PERMIT ISSUANCE ronlractors to construct the project(Sec.7044,Business and Pr fessians Code: The Contractor's License Law don nm apply to an owner of property who ALTER-DRAIN A VENT-WATER(E/0 Wilds or Improve themon, and who contram for such ptajects with s opo ctorw licensed pursuant to the Contnaor's Ltrcom Law. FEE SUMMARY LJ I am exempt under Sec. B k P C for this reason BACK FLOW PROTFLT.DEVICE OUTSI DE FEES Owner Data DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_ RECEIPT# WORKMAN ave JSATION DECLARATION FDCLURF_S PER TRAP SCHOOL TAX Y_ N— RECEIPT hereby affirm that I have a certNcate of consent to self-inurre,ora RECFRT# certificate ofWarkeri Compensation Insurance ora mrtif4d copythertof(Sec. GAS EA.SYSTEM-1 INCAOUTLETS PARK FEE Y N 3800,lab C.) IWiry# GAS EA.SYSTEM-OVER 4(EA) RECEIPT Com nes t-a 'r4D (rGtt BUI LDING DI VI SION FF.ES CCEAified copy is herebyfurnished.the GRFASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE �Certificd ropy V filed with tM city inspection dlv6lon. CERTIFICATE OF E)(EM PTION FROM WOR KERS' GREASE I]tAP PAID COMPENSATION INSURANCE SEINER-SANRARY-STORM EA 71%1FT Date Rtbmi tp IS'. (rhbscction need not be completed lithe permit b for one hundred dollars (SIM)orleea.) ENERGY PEE Y N_ Iostifytha bribe performance ofthe work forwhlch this penult lsisurN, WATER HEATER W/VENT/EZECTR — 1 shall not employ any person In any manner so as to become subject to the WATQt SYSTEM/TREATINL Workers Compensation Laws of California.Date PAID — z Applicant NEW RESIDFMIAL PI.MB. SQ.FT. Date Recei tk Z O NOTICE TO APPLICANT-.If,after making this Certificate of Exemption,you should become sabject to the Workers Compensation provisions Of the Labor TOTAL: CC V7 Cod,you muatforthwith eamplywith such pmWbnoorthis pertNtshall be 32C Wj deemed revoked. B ILDING - CONSTRUCTION LENDING AGENCY SEISMIC FEE O tl O Iherebyafflrthat there h a ronstructlon lending agency for the perform ' ELECTRIC FEE Z ams,of the workfm or which this permitbuPLUMBING FEE ured(Sec.3097,CN.0TOTAL: ) (� O T,ndcrs Name `/_/�/O- Q IL F LendcrsAddm,a �/ QTY. MECHANICAL PERMIT FEE MECHANICAL FEE OW I certitythat l have mad this a Iccatlon and statethat the above information C ixmrm".Iagree tocomply with alldtyandcounty ordimnmandss.t lI. • PFRMITISSUANCE FEES AID: S� >. relating to Wilding construction,and hereby authortre representatives ofthls Zcity to enter upon the above-mentloncd property for Inspection purposes. ALTERORADDTOMECH. -2 ILL (We)agree to save,Indemnify an d keep harmless the City of Cupertino Receipt# V .garnet liabilities,Iudgments,mstund expenses which may In anyway ammo AIR HANDLING UNIT(rO 10,000 CFM) SUBTOTAL: againstsalQ City naequence of the gra nUng of this permit. p (/ nro /— 1 _�/ AIR HM,1DONG UNIT(OVER I0,000CFM) CONSTRUCTION TAX , Signature of AHAZA HAZARDOUS MATERIALS ( Date IXHAUST FLOOD(W/DIKT) CoNSTRUCTION TAX PAID: HAZIRDOUSMATIiRIALS UISCIASURE CO 4 P —/TAX PAI Will the applicant or future building Occupant store Or handle hazardous HEATING UNI'T(TO 100,000 BTU) material as defined by the Cupertino Municipal Code,Chapter 9.17,and the _ DatC RCCeI IH I❑ Yn t d Safety Code,Section 25537G 0 R )7 HEATING UNIT(OVER 100,00TU) TOTAL: Will the applicant or future building Occupant use equipment w devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE whicheMt lut.rd mg,me t aircontaminants as defined by the Bay Area At, —� Quality Mansgemcnt DisWNo IlOILFR-COMP PHP OR IOO,IXq BTU) 4 Yo n No have is the h heath& sus rratcdab t.W2555,2W3.Cd2S5er G95 of BOILER-COMP(OVIR 100,000 BTU)thc �� understand atifth buildiy Cod,Scalaru7550.5,ve a tenant, man,that it understand that notify the occupant oat erNuIrc entsw ich that it is my NEW RFSI DFNRAL MECH. °✓Q.Fr. responsibilitytIssuance ce notify Ctheicapantoftherequlmmems which most be met prior t°isuance of a Certificate OOccupancy. Owner or autho sad agent ,a/ Date. y/s ,{D {' TOTAL: ISSUEDB "a'' 7LILGLI �jL✓ OFFICE COPY