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21776 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY Building Project identification - PERMIT NO. Building Address: 21776 a wrmro ams: one: , CITY OF CUPERTINO-BUILDING DIVISION Lfa.Nu: APPLICATION /PERMIT C.Mel Nannez BUILDINGELECTRICALPLUMBINC-MLCHAMCAL CATEGORY CONTROL ArchltM/Engine= Lm . .N. QTY "ELECTRIC PERMIT FEE BUILDING PERMIT INFO Add. ` S. PERMITIS5UANCE" ❑ ❑ [� ❑ LICENSED CONTRACTOR'S DECLARATION VJ I hereby affirm that l am Licensed under provisions of Chapter 9(mmmrnc APPLIANCES-RESIDENTIAL JOB DFSCRIIUK)N tngMt11...hSaabllto.and efflon3o(theguslncuand PmfesaionaCode,and my - ya limns Ise fun fora and effect. _ PANEIS LI s m C Class LmN. D.tc Date ContractorUP TO 200AMJ�S ARCHITECTS DECLARATION 701-1000 AMPS re O❑ I understand my platy shallbe used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT. k d U Licensed Professional SIGNS ELECTRICAL : OWNER-BUILDER DECLARATION SPECIAL CIl2CUIT/MISC I herebyaffirmthat Is.c.cmpt fmmthecmdrador's Llcense7awforthe following reason.(Section 7MIS,Business and Professions Code:Any dty or O TEMP.METER OR POLE INST. K,S cauntycture regrmItsperMte,alsoequireatheaprove,demonsh,ormit to any structureprlemeltshat heir also sed puatheapto the provisionorsuch s of to POWER DEVICES floe a actors statement that he licensed pursuant it the tion 7 ) of the 3p� Contractors License Law(Chapter9(commencing with Section 7")of Divi- SWIMMING POOL ELECTRIC alon3ofthegusinemand PmfemlomCode)orthathel.eumptihemfmmand VALUATION _ the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHE-rFIXTURES �� appllant(ora perMtsubjectstheappncanttoacivll penalty of not morethan $ five hundred doll..($5M. NEW RESIDENTIAL ELECTRSQFT. STORIES TYPE CONSIRIICTIO I,as owner of the property,or my employees wit h wages as their sole compensation,wllldothe work ancithe structure is not Intended or offered for $,, O min(5==.7044,Business and Professions Code:The Contractors License Law ,pp11 $ does net apply to an owner of property who builds or Improves thereonand s„S^ who does such work himselforthrough hlaownemployces,provided that such \OCC.GROUP RIS.UNITS Improvements are not Intended oroffered torsade.If,however,thebullding or TOTAL: improvement issold withinoneyearofcomplelion,(heenmer-bunderwlll have the burden of proving that he did not bund or improve for purpose of sale.). QTY, PLUMBING'PERMIT. FEE ML as owner of the properly,am exclusively contracting with IlFLOOD ZONE APlicensedPERMIT ISSUANCE contracts.to comwct the project(Sec.7044,Business and Protamines Code: The Contractors License Law done not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) Wilds or Improves thereon, and who contracts for such Inners with • FEE SUMMARY 15ador(.$)mmmsed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE LJ I am exempt under Sec B &P C for this musnnOUTSIDE FELS i ga` Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY RECF]PTN p WORKMAN COMPENSATION DECLARATION r�.hereby affirm that I have a arlifiate of consent to self-Insure,or aFIXTURES PER TRAP SCHOOL TAX Y_ N_ ceroficate ofwo,kmCompematimlr mnmoraarlifiM copythereof(See. RECEIPT 3800,Isis C.) GAS F.A.SYSTGI-1 INCA OUTLETS PARK FEE Y_ N_ policy �pO�Y�a� GAS FA.SYSTEM-OVER MA) RECEBrfM Com anv BUILDING DIVISION FEES On copy la herebyfurnished. the GREASE/NDUSIRL WASTE INTERCEPTOR PLANCHECKFEE L�7o/'-'ertified espy b(fled with the sty Wpedlon division. CERTIFICATE OF EXEMPHON FROM WORKERS' GREASETRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM F.A.Ran. Date RCCCI lb (TFlaeedlon need not be completed If the permit b foror�e hundred dolls. ($1I3)orlem.) 1 WATER HEATER W/VENT/ELECTR �T ,c�� ENERGY FEE Y N Sanmtymplothat anypemnihe mnyt nnerwweek wto this permit is Issued, pr cw.(.J — I shall nm employ any person In any manner n es to become subject to the WATER SYSfG1/TREATING Workers Compensation lawn o(Califomla. Date PAID - zZ Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t# Z O NOTICETOMPLICANT:ILaRermakingthb Cenlfiateof ExcmElton,you should become subject to the Works.'Compensation provisbm of the Gabor TOTAL: ~ N Code,you must forthwith comply with such provisions or this permit shall be W > deemed revoked. BUILDING CL C CONSTRUCTION LENDING AGENCY SEISMIC FEE I hereby affirm that there is a construction lending agency forthe perform- ELECTRIC FEE 7 Z anaoftheworkfor Whichthi pe,mb mued(Sec.3097,CIv.C.) TOTAL: U O Lender'a N.rtn PLUMBINGFEE ly _" Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE OO I omify thall haveread this application and statelhat theabove Information aBeorrect.Iagreeiocomplywithallcityand countyordmanes and statelaws PERMITISSUANCE FEE—PAID: } relating to building mrotrudlon,and herobyauthoriureprexntativeso!this F.. Z city to enter upon the above-mentioned property for Inspection purpoaea, ALTER OR ADD TO MFCH. Date RCCCI fA _ (We)agree to save,Indemnify an d kap harmless the City of Cupertino P against liabNtles,judgments,mg...d expenses which may lnanywayacwe AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: aga Wt mid City Inconsequence of the gra rating of this permit AIR HANDLINGUMT(OVERI(L"CFM) CONSTRUCTION TAX DateSignature of AppBmnt/Contractor Dam FxHAusrxoDD hY/nuc. CONSTRUCTION TAX PAID: HAZARDOUS MAT RIALSDISCLOSURE Willtheapphe"nt or future building occupant store or handle havardoua HEATING UNIT(TO 100,000 BTU) Date RCcei I# material as defined by the Cupertino Municipal Code,Chapter 9.17,and the - IlreNo ❑ltYaanndSafetyCedl$�S,nell n75532(a)7 - I SEATING UNIT(OVER 100,000 BTU) TOTAL: Will the applicant orfummbuilding occupant use equipment or devices VWJILATION FAN(SINGLE BESIDE ISSUANCE DATE ge which emit harE nedefined see dennd by the say Area Air PAM ' Quality w y Magcnneat snt Df1 ct7 BOILER-COMP©l-B'Dft 100,100,000, BTU) ❑Yea No I have read the h. nus materials requirements under Chapter 6.95 of BOILER.C'OMP(OVER 100,00(i BTU) the California Health&Safety Code,Sections 75505,75533 and 75534.I SMaI LNr` underata ad that if the building does not currently have a tenant that it is my NEW RESIDENTIAL MECH. SQ.Ff. responsibility to notify the occupant of the requirements which must be met prior to luce Of a Certificate of Occupancy. ETryry Na Owner or authormt!agent Date ISSUE (.. TOTAL: OFFICE COPY —