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21616 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Bulldinx Project IdentificationPERMIT NO. Building Ad Q 4 �� 21616 erre. one. - APPLI�I LUN bUtuolk IAL UA 11, CITY OF CUPERTINO-BUILDING DIVISION - � Cunt ,'a Name: Lie,No: APPLICATION / PERMIT L� SBUILDINC-ELBCTRICAI PLUMBINGMECHAMCAL CATEGORY CONTROLN Architect/Engineer. Lic.Na: 4TY ELECTRICPERMIT "FEE BUILDING PERMIT INFO Adtlreap J_ / a_a_ PERMITISSUANCE Z� ❑ LICENSED CONTRACTOR'S DECLAMATION Ihereby actionaffirm that iv Bcroseunder eBusinemand mfesofChapter9(emmme- APPLIANCES EMfAL BDFSC inenseISection 70W)to.anDlvfect. fthcBusinewandprofssponsGaac,and my REPTION license binfell force and c.It PANELSLice - Date Chw W ntr Dale Contractor ARCHITECT'S DECLARATION 701-1000 PS 9�y O I understand my plain shall be used as public records. .OVER 1000 AMPS SQ.FT.FLOOR AREA $/9Q.FT. E z o Licensed Professional SIGNSELEG ]6 OWNER-BUILDER DECLARATION SP�CIALCRCUIT 7 t'yd.-Za I herebyaflrm that Iam exempt from the Contractors License Law for the I pp following reason.(Section 7m1.5,Business and Professions Code:Any city or OZtiutras TQdp.METER OR POLE] ST. county primo It permit to construct,es,thlter,e applicant fors ch,orrepatr q Q any strocturepater.��t�hat he Is alsorequires, pursuant to the provision of tin POWER DEV] file a signs statement that he h licensed pursuant to the provisions of the OW Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWEs1MIN'C IA70L ELECT pon3efthe Buelneuand PMessbns Cee)er.hat hehexemptthere(romand VALUATION Sr' the balls for the alleged exemption. Any violation of Section 7WIS by any �s A , t p appbcantforaperMbubjedstheappllcanttoadvilpemltyofnatmorethao - OTTLETSSWITCHFSFI%'fURES' ♦W 4/r �Q�� QQ� Eye hundred ownerofthe p0). NEW RESIDENTIAL ELECTR SQ.FI, STORIES TYPE CONSTRUCTION �n ❑I,esownere(theproperty,or dmy employeeswithinwagesrthelesole ck,(See Hon,Business willdothe kandthes Code:rThno.intendedo scene Law q d for vie(Sec 7044,Bu aniew owner fpreaarty Code The hu ilds or improwas mactots License Law docs notsuchapply ork owner o(propmty whonemporees,provided that such OCC.GROUP RES.UNITS 0. who does surhworkhimself or through hisownemployees,provided ihatach Improvements arc net Intended oroffered for sate.If,however,thebuliding or TOTAL; "M% improvement hsold withinone)earofcompldiorytheowner-builderwlll have tryLIl+rden of proving that he did not build or Improve for purpose ofule.), QTY. PLUMBING PERMIT FEE FLOOD ZONE APN 11 L as owner of the property,am exclusively wntrac.ing with licensePERMITISSUANCE r� contractors to consumer the project(Sec.7044,Business and Professions Code: The Contractor's License Law does not apply to an owner W property who ALTER-DRAIN VENT-WATER(EA) builds or Improves thereon,and who contracts for such p(ojec s with a alLs CO CgB}teec etoe(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY LJ 1 am exempt under SB &P C for this masonOUTBID Owner Data DRAINS FLOOR ROOF,AREA,COND. SANITARY Y— N— • RECEIPT p WORgNAN COMPENSATION DECLARATION FI%NRES.PER TRAP arta SCHOOL TAX Y N— ❑I hereby affirm the.I have o lrtu rate of consent m self-Insure,(Sa a RECEIPT N cern,IcabC.) rken'Camperue.lonlmurance we certlfkd wpytM1emof(Sec. GAS EA.SYSTEM-1 INCA 380D,Polis lab C.) PARK FLE Y_ N Collry p RECEGAS EA.SYSTEM-OVER 4(EA) DING DT M CBUILDING DIVISION FEES Certifie copy is hereby fumishe. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE Certified copy h filed with the city inspection division, CERTIFICATE OF E%EM PITON FROM WOR KERS' GREASETRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2()NT. Date ReceI tit (I'Msuctlon need not be complrte If the perMt h(w oro hunarcd dollars (slm)nrlyth WATER HEATER W/VENT/ELECTR ENERGYFEE Y N I cent empat loy he any person in any Int work so as to b this permit ubj ct to the — Ishallnotemployanypersoninany,'mons,'nw.o berome subject to the WATER SYSTEM/TREATING Workers'AppCompensationompematlon laws o(GII(omh. Date pAlp O Z NOTICE NEW RESIDENTIAL PLM B. Date Recei t# Z O NODCE co e..bje ttothe after maklng om a sationCertiflcateofonsofthe eLyou �'� H should ode,yo must it the Workers'such pruasonpmvhiomrmit slab be TOTAL: W N Coda you must forthwith ewnpiy with each provisions or this permit shall be j seemed revoke. - —.BUILDING W — CONSTRUCTION LENDING AGENCY SEISMIC FEE CL C Ihereby a(firmthat them h a construction lending agency forthe perform ELECTRIC FEE 7 Z ance ofthe work for which this permit h issued(Sec.3097,Civ.C.) TOTAL: V O Lender's Name PLUMBING FEE eQ LL t- Lender's Addrew QTY. MECHANICAL PERM IT 'FEE'.. MECHANICAL FEE O O I certilythat l have read thisapplicatienand statethat the above information C Is normal.I dgree to comply with all city and county ordinances and state laws PERMIT ISSUANCE PEES PAID: >_ IL to building construction,and hereby authorize representatives ofthis H Z city to enter upon the abovo-mentlone pmNrty for inspection purposes. ALTfRORADDTOMECH. — (We)agree.o save,Indemnify an d keep harndess the City of Cupertino Date RCCeI tN agabut Whillties,judgments,cops and expenses which may In any way amus AIR HA NDLING UNIT(TO 10,000 CFM) SUBTOTAL: against said City In wnaequeme efth antingale permit. _ AIR HANDLING UNIT(OVER 1 gm0CFM) CONSTRUCTION TAX Sigmmrc of Appllwn ontrac.or Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PA ID: HA2ARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle haaardous HEATING UNIT(TO 100,000 BTU) Date 'RCCeI Iq material as defined by the Cupertino Municipal Code,Chapter 9.12,and the - H,ahhand Safety Cee Bection25.532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: N ❑ Yea No Will the applicant or ,cure building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) ISOSU which emus hazardous air contaminants as defined by the Bay Area Air - - Quality Management District? BO(LFR-COMP DH POR 100,0(0 BTU) 4Ye, f1 No have read the Health &S cam materials Se lam 25505, 5533 and 255 .1 of Ii07LER-COMP(OVER 100,000 BTU) Ftk; the Czlitod is Health&Safety Code, et cum25505,ve.tenant, that '„ YIG IA understand that notify he building occupant not a rrcn0y have tenant,that i. met NEW REST DFN7IAI.MECFi. IQ.Ff. responsibility ce ofaCertificate occupant d.he requirements which must be met prior to issuance cafe Certllkate of Occupancy. All +---�J - Owner or authorized agent Data ISSUED[I TOTAL: OFFICE COPY