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22121APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Pro'ed IdentlRgtlon- - - - Building Address: al 89© 17r PERMITNO. n /7 a� 1' a� G G I G I sere arts: - one: MW -eV [Cg- a5a-q/qo CITY OF CUPERTINO-BUILDING DIVISION APPLICATION / PERMIT BUILDING-ELECTRICALML BINGMF HAMCAL ^ G c lmaoraName: / �q uc.Na I� N LIGWTri _35— f 3 CATEGORY CONTROL N Architect/Engineer: - Lk. N. qn','• •'''.BLECTRIG•PBRhIIT "pEE BUILDINGPERMIT INFO Address: ❑ El PERMITISSUANCE LICENSED CONTRACTOR'S DECLARATION ' ' Ihereby affirm that l am Ecensed under Emotions of Chapter 9(mmmenc- ingwith Sedion7000)ofDivisl3o(the Busi.,snd Profe.sionsCode,and my license Ie In full f d efon fect 3� License ea Lk.nN D Date CotractorA:2� An ARCHITEcrs DECLARATI IJ I understand my pUrs shall be used u public records. Licensed Professional - OWNER -BUILDER DECLARATION I hereby affirmthat l am exempt fromthe Contractor's License Law for the following reason. (Section 7031.5, Business and Professions Code: Any city or muntywhichrequiresapermittomm, d,altep Impmve,demolish,orrepalr anystmcture prlorta Its issuance,alsorequlrestheappllant forsuch permit to file a signed statement that he k licensed pursuant to the provisions of the Contractors License law(Chaptsr 9(commencing with Section 7000)of Divi- ,on 3 ofthe Business and Pm(easlonsCode) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 70313 by any appBoom fora permit subjects the applicant to a civil penalty of not more than flue I, as neroftdollars (epm ❑T, as owner of the property, or my employees with wages m their sole d for com(Sec.7 on, Bukreihework andthestCode: Th Contractornat intended or License Law sale (Sec. apply to alnowand f property Code: The Contractor's L erean Law whododoes tapply torn owner of property who nempoyImproves ovided thatand whoovessuch mentsa notintended ntelfor edorough his owne. If,ho eprovidedihatsuch Improvements sold within dneyearf red complation If, howeveg deer ldi g orhave Improvement lesoldwithln oneycarofcompldlogthe ownervbullderwlll have ifdeas n of proving that he did not build or improve for purpose of sale). owner of the property, am exclusively contracting with licensedcontracto Businessas nand Protestor Code: aco ronLWatthe eLaw oect (Ser. apply The The Contractor's Liana Law does not apply m an owner of property who Wild. or improve thereon, and who contracts ice such p(ojem with a the Contractor's License ae Law. on ctorexmpt under ant Sec. LJ I am exempt under Sec. B & P C for Nb reason APPLIANCESRESIDENUAL' JOB DE9CR1PT[ON I ('C PANELS UP TO 200 AMPq 201.1000 AMPS OVER 1000 AMPS SQ. FT. FLOOR AREA S/SQ. FT. _ SIGNS ELECTRICAL SPECIAL CIRCUIT/M1SC TIMP METER ORPOLE [NST. POWER DEVICES SWIMMINGPOOLELECTRIC OUTLETSSSWITCHES-HXTURDS VALUATION,, © D s NEWRESIDENTIALELECTR SQ.FT. Z 5 RIPS TYPE CONST74UCTION' - Z TOTAL: ,. LUIN �Ty>';'f: �•`•', '.PMBG'PERMF IT EE.:: OCC.GROOP RES. UNITS PERMIT ISSUANCE ' ALTER -DRAIN & VENT- WATER (EA) FLOOD ZONE AtvPN "PEE S IMMARY' BACK FLOW PROTECT. DEVICE DRAINS FLOOR, ROOF, AREA, COND. pD(TURES PER TRAP- SANITARY Y_ N_ RECEIPT N Owner am WORKMAN COMPENSATION DECLARATION E31 hereby affirm that I have a cedmcate of consent to self -hours, ore certificate a Wmkera'CompsootimInsua rsnora certified mpythereof(Sec. 3800, Lab CJ Policy N SCHOOL TAX Y_ N_ RECEIPT N GAS EA.SYSTEM-I INCA OUTLETS PARK FEE Y N RECEIPT N GAS EA. SYSTEM -OVER 4 (EA) Cam anv�', BUILDING DIVISION FEES ❑pCertlfled copy hereby turn) ed. �Cerlified ropy V filed with the dtyWpMlon division. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need net be completed BtM permit V Torose hundred dollars 011m) or leas.) Iadifythat in theperfarromm (thewak forwhichthts pereatlsbmed, I shall not employ any person In any manner so as to become subject to the Workers'Compensation Laws of California. Date Applicant NOTICE co a kable AM: a ager making this Certificate o(Excmpt a Lyou Code,shoulyoumostforthwithto Code, revol of (octhwith comply with such provisions orthls permit shall be co plywit Comprovisins orthowrmit s lab be deemed revoked. - ' CONSTRUCTION LENDING AGENCY I hereby affirm that there he a coustmctlon lending agency for the perform- ance of the work forwhich this permit is Word (Sec. 3D97, Cls. C.) Landers Name7-7 Leaders Address I cedlfy that] have read thisappliationand statethattheabovelnformatlon Is correct.I agree to complywith all dlyand county ordinances and state laws relating to building construction, and hereby authorize representatives o(this city to enter upon the above-mentlmud property for inspection purposes. (We) agree to save, Indemnify an d keep harmless the City of Cupertlno against liabilities, judgments, mets an xpensm which may In any way accrue again, Cl In cons ence egram his permit. GREASEANDUSTRL WASTE INTERCEPTOR - PLANCHECK FEE PAID Date Recei t# GREASE TR" SEWER -SANITARY -STORM EA. 200FT. WATER HEATER w/vENT/EI-ECTR ENERGYFEE Y N - PAID Date Recei t# WATER SYSTEM/TREATING NEWRESIDENTIALPLMB. SQ%T. - TOTAL: BUILDING FE • 0 0 SEISMIC FEE ,T -O TOTAL: - ELECTRIC FEE '.,.� QTY. j. 'ivIBCHQNIGAVPERM[T i +''.-f FEE', PLUMBING FEE MECHANICAL FEE PERMITISSUANCE FEES PAID: ALTERORADDTOMECH. Date Receipt# AIR HANDLING UNIT (TO 10,000 CFM) SUBTOTAL: - AIR HANDLING UNIT (OVER ID,00oulso CONSTRUCTION TAX 'SIgnature of Applicapt/ ontrador 9to H RD OUSMATERIALSDISCLO URE Willtheapphc Iorfuture building occupant store or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code Section 25532(.)7 E] Y- ,L+,—J, No Will the applicant oQturc building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Arca Air Qia lity Management District? Yes ❑No have read the hazardous materials requirements underChapter6.95 of the California Health & Safety Code, Sections 25505, 25533 and 25534. I understand that tithe building does not currently have a tenant, that It is my responsibility to notify the ocapa'I of the requirements which must be met Prior ua o i!1 _ Occupa - 6 D(IiAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID: HEATING UNIT (TO 100,000 BTU) Date Recei f# HEATING UNI ((OVER 100,000 BTU) TOTAL: '• Jl ff VEWITLAT70N FAN (SINGLE RESID) ISSUANCE DATE 1L3(I� Moto R 1, ISSUEDBY: BOILER -COMP OHP OR 100,000 BTU) BOILER-COMP(OVER 100,000 BTU)„ NEWRESIDEIA NTL MICH. SQ.FT. Owner or authorized nt ate TOTAL: OFFICE COPY