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21443 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY —Building Protea Identification PERMIT NO. Building Address: 21443 77I neva G: `� �! yyG—=Phone: f f CITY OF CUPERTINO-BUILDING DIVISION I1 1 Contradm'.Name: LIcAft .No: APPLICATION / PERMIT 6l, ULt/i✓L�'L BUILDING-aE RICAIPLUMBING-MECHANICAL CAITGORY CONTROL# Architect/Engineer. Lk.No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: PIIIRMITISSUANCE ❑ LICENSED COemwd under pr DECLARATION I hereby Busiestannsof Chapter ssions9(rommen APPLIANCLSRESIDENTAL JOB DESCRIPTION iI...1 i cion force of DlWfect. ofthe Businessand Profeaslon.Cole,and my License Is In(uB force dna erred. PANELS �L-+_ _S•.au,�a License CWm LM.# f �J�/G-- Oate Contractor UP TO 200AMPSI-W t�0 ARCHITEe usedDECLARATION OVER 030 AMP"' cc0 2 I understand my phra e W I W used u public records. OVER 1000 AMPS SQ.FT.FLOOR AREA f/SQ.FT. z❑Oq U Licensed Professional SIGNS ELECTRICAL "N OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC - ^ zf, � Iherebya(flrm thatI am exempt from the Contractor'.License Law for the QQ (oeowing...($action 7031.5,Business and Predestine.Code:Any city or i"'u7 county which requlrsea permit tomrokuct,alter,improve,demolish,orrepair TEMP.MEM OR POLE INST. y 7 anystructure pdorto Its Issuance,also requlrestheappllcant forsuch permit to POWER DEVICES rN1 y file a signed statement that he Is limeaed pursuant to the provisions of the Ow(� Contractor's License Low(Chapter 9(cernmencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION 15OJ slon3ofthe Business and Pro(emne loCode)orthat he Isexempttherefromand '77 the Wats for the alleged exemption. Any violation of Section 7031.5 by any RR / appU.ekfor a permit subban the a ppilcant to a civil penalty of net more t n OUTLETSSWITC}{ESEXTURFS five 1,as o nerdolof the p0). NEW RFSIDFM[AL ELECIAP_SQ,FT. STORIES TITS CONSTRUCTION I,ea owner lido t property,or my employees with waged their sole compensation,Business andhe Pr end rsaimstrode:Th Commmeot intended or rows d forLaw 1// u 5 ❑ sale(Sec. pply to Businessand prepeloro Code:The or fimpaora Llcewe Law $ docs not apply to an owner of property who builds or Improves thereon and OCC.GROUP RIS.[NITS C: whoaoementsa nhimselfedorough Msowne,If,hoeevertdedthaI A improvements am not Intended oro(fercd forwle,ILhowevegthe bull �(Qr ' I TOTAL: improvement hsold withinoneyearofcumplation,the owner-bullderwllTh ve -t t rden ofproving that he did not build orimprove lorpurpmeo(sal.s� QTY, l q LUMBIIV PE IT °� FEE [:IppD ZONE APN 1.as owner of the property,am exclusively contracting with BcenosdeBE ntracton to construct the project(Sm 70K Business and professionsC t PERMIT ISSU Contraaoe.License Lw does not apply to an owner of property wFo /J A fids or Improve.thereon, and who contracts for such pwiects with a ALTER-D 4s VENT-WATER(EM actor(a)licensed pursuant to the Contr ct.e.License Law. p FEE SUMMARY I am exem t under Sec. B k P C for this means BACK FLOW OTECT.DEVICE Owner I l..�.. Date � DRAINS.FLOOR ROOF,Aa YCOND. SANITARY RECEIPT WORKMA COMPENSATIONDECLARATIO P0('NRES PER TRAP SCI;OOL TAX Y N ❑I hereby affirm that I have a certificate of consent to self-Insure,ora RECE T# certificate of WorkerYCompmuatlonlnsurance ora certified copy thereo((Sec. 380011,0C.) GAS F.A.SY -T ING.4 DUTLETS PARK FEE Y N PolCo Policy GAB-FA.SY rERd(EAI RECEIPT J, MY BUILDING DI VISION FEES C.hifiedcopyIn 6fil hereby tumished. GREASEANDU L WASTE INTERCEPTOR PLANCHECK FEE MCertltled copy Is(fled with the city InepMian divlalon. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP FAIR COMPENSATION INSURANCE SEWEtSANITARY-STORMEA 20017 Date Recei [# (this section roadnd W completed If the permit Is forona hundred dollars (f100)ftifytJ WATER HEATERW/VENT/ELECTR ENERGY FEE Y N (certify that emin ploy anyhe arson i any m neerworso se to rahTs s,subjrmitect c Issued, - I Whale not employ any person In any manner Wo u to become aub�ect to the WATER SYSTEWTREATING Workas'Compensatlon Laws of Gll(ornh.Data PAID — Z Z Applicant homes, NEW RESIDENTIAL PLMB. SQ.Fr. Date Recei t# O NOnCE licant APPLICANT.If,akar making this Certificate o(Exemptlon,you F should bee subject to the Workers'Compensation provIsiom of the Labor TOTAL: Ln Code,you=at forthwith comply with such provlslorm orthls Ferrell shall he ]' deemed revoked. BUILDING FEL aCONSTRUCTION LENDING AGENCY SEISMIC FEE I hereby affirm that there Is a com uctlon lendingagency(or the perform ELECTRIC FEE Z ante of the work for which this permit Is tasued&c.3097,Civ.C.) TOTAL: V O Lender'.Nave PLUMBING FEB LL F Larder's Addreaa QTY. MECHANICAL PERMIT FE E MECHANICAL FEE O W I mAilythat l haverealthts application and auto that theaboveinformation �` l 0. facetted.lagreemcomplywlthallcityandcountyordlnance.and state laws PERMIT ISSUANCE db FEESPAID: >. N relating to building conetmotion,and hereby authorize representatives of this [— Z city to enter upon the above-mentionedER property for Impection purposes. ALTORADDTOMECH. Date R('.Cel [# V _ (We)agree tont ,Indemnify an d keep harmless the City of Cupertino against llabllitles' gmenre,meta and expenses which may In anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: i agaiwtaald ronsequ nre o(thc gr intlegefthlsperenit. / �y`9 AIR HANDLING UNIT(OVER IaW0CFM) CONSTRUCTION TAX tgnatum of Applicant/Contmetor Data EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) - materialasdefinedbytheCupertinoMuNcipalCode,Chapter 9,1 Z and the Date Reuel t# Health and Safety Cade Section 25537 W 7 HEATING UNIT(OVER 100,00D BTU) TOTAL: . ❑ Y. No Wllltheapplieset or mmbuiidingoaupantumequipmentardevims VENTILATION FAN(SINGLE REED) SUANCE DATE 'which emit harardous air contaminants as deflned by the Bay Area Air Pill V��,fyf/� uta lily Management DlsMa7 BOILER-COMP AFB'OR l00,OW BTU) Q 1 v. No have read Healthe h fcty Code,ls action underChapter 2S54.I of BOILER-IbMP(OVIIIR 100,000 BTIn �� S �O the ersta dt Health building Safety Code,cut currently 75505,ve a toad 25534.1 understand thatlithe tify the occupant of to requirmnts which that It is mybe NEW RESIDENTIAL M(ECFI. SQ.FTresp . prior Ie160Ryto of.Ceheoc to ofOttherequimmentawhich must be-met � F( 1M prior to Issuance o/a Certificate ofOmpancy. ^^'''�j'R7f'�� RR--pp.�-� '�II��'�� ��� aa�� Owner or autharized agent _ Data ISSUED B :*]jpW1�V•�•QCl TOTAL: .� OFFICE COPY