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21907APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY OFFICE COPY Building Address: PIiItMIT NO. Far.. �O �J 21907 J� CITY OF CUPERTINO, BUILDING DIVISION APPLICATION / PERMIT BUILDING-ELECTRICALPLUMBINGMECHAMCAL A °"tress Lle.No: etretter.,Engineer.I Lk, No: CATTGORY CONTROL N QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO Address: PERMITISSUANCE ❑ ❑ © ❑ • LICENSED CONTRACTOR'S DECLARATION I hereby affirm that Ism licensed under providers or Chapter 9(mmmerec. ingwlth Se Uon7000)ofD slon3ofthe BusinessandPmfnslonsCods, and my If--- bIn (prrn and ns Licee Class"Li,., Date Contrador APPUANCESRESIDENTIAL PpN©mac JOR DESCRIPTION ARCHITECTS DECLARATION I understand my plans shall be used u public remrds. 201-1000 AMPS OVER1000AMPS SQ, Fr. FLOOR AREA 9/SQ, FT. Licensed Pr fosslorml SIGNSELECTRICAL OWNER -BUILDER DECLARATION I hereby affirm that l am exempt from the Contractor's License Law for the finumving reason. (Section 70115, Business and Professions Code: Any dty or county which requires a permit to mrutma, alter, Improve, demrlbh,er repair any structure prior to its Issuance, also requires the applicant for such permit to Bk a signed statement that he is licensed pursuant to the pmvIsiom of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Divi- go. 3 ofth.Bugnessand Professlora Code) or that he Isexempt there(romand the base, for the alleged exemption. Any violation of Section 7071.5 by any applicant for a permit subjedstheapplicant to a civil pensity of nes more than five hundred dollars (5500). ❑ I, as owner of the pmperty, or my employees with wa es as their sok rompenmfion,wRl do the work and thestru ere isnot intended or offemelfor ask (Sec. 7044, Business and Prolessioae Code: The Corhact°ls License Law does nes apply to an owner of property who builds or improves thereon,and who does such work himself orthmigh hisoweempleyees, provided that such Improvements are not Intended proffered fmasie. If, however,thebuildi ifor Improvement baold withlnomyearofcompI&mo,the owner-bullderwill have the rden or proving that he did net build or Improve for purpose ofule.), L as owner of the pmperty, am exclusively contracting with licensed contractors to camtma the project (Sec. 7044, Business and Pmfesslees Code: The Contender's Limmo Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such pinjmts with a c adrr(s) licensed pursuant to the Contractor's Lure. Law. I am exempt under Sec. B k P C for this reason SPECIALCIRCUIT/MISC TEMP. METIER OR POLE INST. POWER DEVICES SWIMMING POOL ELECTRIC OUTLETS-SWITCHESFIXTIR2ES VALUATION NEW RESIDENTIAL ELECIR _SQIT, S TYPECONSTRUCTION TOTAL: GROUP NES. UNITS QTY, PLUMBING PERMIT FE$ PERMITISSUANCE ALTER -DRAIN& VENT -WATER (EM FLOOD 20NE APN BACK FLOW PROTECT. DEVICE FEE SUMMARY Owner Data DRAINS FLOOR ROOF, AREA, COND. FIXTURES PER TRAP GF, SYTE-1 INCAOUTLETS SANITARY Y IN RECFRrI' N WORIQvIAN COMPENSATION DECLARATION ❑1 hereby affirm that I have a certigate of consent to self -Inure, or certificate of Wor4en'Crmpewtion Imearana or a credited ropy thereof Sec, Lab Cj Pulley It 6F9,� SCHOOL TAX YPNN ECQC NN3800, PARKPEY RECENT— CemR GAS EA. SYSTEM -OVER 4 (EA) erti0ed ropy Is hereby furnished. ❑ Certified copy is filed with the city Inspection division. BUILDING DIVISION FEES GREASE/INDUSHtL WASTE INTERCEPTOR PLANCHECICFEE CERTIFICATE OF 10(EMPCION FROM WORKERS' COMPENSATION INSURANCE (Thtssedlonneednabecomptded BtheperMtbforormhundmddollars (SI W) or less.) GREASE TRAP PAID Date Receiptk SEWER-SANITARY-SIORMEA. 2001T. WATER HEATER W/VENC/ELECTR ENERGY FEE Y_ N_ DBIQ RCCY+1 Ig Icertify that in the performance ofthework forwhleh this Permit is taxied, I shall not employ any person in any manner so as to became subject to the Worker%Ctempensstion laws of California. Data ApplicantPAID WATER SYSTEM/TREATING NOTICETOAMICANT:lf, aftermakingtNe Certlfiam..IExemptlen,you should become subject to the Worker' Comperuation provbiam of the Labor Code, you must forthwith comply with such provIslom or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY Thereby affirm that them bm aretuctlon lending agency for the perform- znce of the work for which this permit is Issued (Sec. 3097, Civ. C.) Land era Name '�WRESIDPN"PIAL PLMB.__SQ,ET, TOTAL: . TOTAL: (Jctl BUILDING E SEISMIC FEE ELECTRIC FEE Lender's Addmres Iartifythatlhavereadthisappllationandebtathaitheabovetnformadon acumen. l agmsto Comply with all city and county ordinanmsand gate laws relating to building corauuction, and hereby authorize representatives of this city to enter upon the above_mentioned property for Inspection purposes. (We) agree ave, Indemnify an d keep harmiess the City of Cupertino :agamatllabi as, elgmenis, cotsand expenses which may In anywayaocnee 9-1-t .1 It Immsuequencaofthe ranting of this permit. QTY. 'MECHANICAL PERMIT �E PLUMBING FEE PERMUISSUANCE ALTIRORADDTOMECH. AIR HANDLING UNIT ITO 10,030 CEM) MEGI-TANI LFEE PL•ES PAID: Date ReceiPtif SUBTOTAL: AIR AIR HANDLING UNIT(OVER i g000QM) CONSTRUCTION TAX 5p/ Signs t sre ofF Fusco//,, not or HRDOUS MATERIALS DISCLOSURE Date AYA Will the applicant orfutum building occupant store or handle hazardous material as defined by the Cepemino Municipal Code, Chapter 912, and the and Safety Code Section 25532(a)7 ❑ yO9 N`O Will the applicant or tore building Pant use equipment or devices which emit hazardous air comMn a eaas defined by the Bay Arca Air Qua lily Matugcrrcnt DIsMa7 Yes (� No 4 CONSTRUCTION TAX PAID: Date RCCCI N!health HEATING UNIT (TO 100,000 BTU) IIEATINC UNIT (OVER 100,OW RTU) TOTAL: VENTILATION FAN (SINGLE RESID) ISSUANCE DATE w/fl BOILER -COMP OHP OR 100,0110 BTU) hawemadthehaze�oesmterlalsrequirementsunderChapter6.95of the Callfonu. l lealth k Safety Code, Sections 25505, 25533 and255 M. I understand that lithe budox, not currently have atenan5 that lte,my roporslbllltyto Really the occupant ofthe requirements which mustbt met prior to issuance of a Certificate of Occupancy.b�ataN . BOIIXR-COMP(OVER100,000BTU) Q9 ��� �(,✓r t//✓ a.{ /y Y W, rupel'I'lna ��� NEW RESIDENTIAL MECH. SQFC - Owner or autharired agent Dute TOTAL ISSUED ��r••Y, BY: L OFFICE COPY