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21302 APPLICANT,TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY ' Building Project Identification - - PE- WTNO. Building Address: 160- - 'c p /7�I O 2 . 75wnev ante: .,` one: A . lK �N CITY OF CUPERTINO-BUILDING DIVISION ,• Contractor's Name: .Lk.No:. APPLICATION / PERMIT +BNLDINGCLECTRICAUPLIIMBING MFLHAMCAL CATEGORY CONTROLaM�� Architett/Engin , Lk.No X400 •i " i" -r i)l' I GI-a BUILDING PERMITANFO... - - ;Q'n `, ELEC1'•R[C PERMIT ;FEE,, t ,' .'.. Addrms: _ PERMIT ISSUANCE,•, ❑ LICENSED CONTRACTOR'S DECLARATION _ LP Ihereby affirm that l am licensed under provisions o(Chapter9(commenc APPLIANCFS-RESIDENTIAL - - JOB DFSCRIFFION, ' ' .ingwith5 ction 70M)of Dlvlslon3 ofthe Businemand Pmfeselons Code,and no License b in fuB force and ic.# PANELS T T License Class ' LIc.N 1 i.--+^, Z Date Comncior ' ARCH ITECI'S DECLARATION 201-IfDOAMPS asaOZ ]undersand myplamshallbeumd aspubilcrecords. OVER1000AMPS SQ.TT.FLOORARFA S/SQ.FF, O Licensed Professional SIGNS ELECTRICAL ,•- ( b 'GFy z fa�rr,, Zo. �6 OWNER-BUILDER DECLARATION SPECIALCRCUIT/MLSC .- �S owing afBrmtbat on 7031 ,Business a Gntractort sCode;h y city or pp county greh requt sat pronottoc rsiness and Professions Code Any city it TEMP.METERORPOLE]NST. � county which rcqulrcsa penNttomnstruci,altegimpmve,dennllsh,or repair 9P v anystructure pdorm its Lwunce,alsorequlresthe applicant for such permit to POWER DEVICTS f5 S file a signed statement that he is licensed pursuant to the provisions of the 3"' Contractor's Law(Chapler9(mmmencing with Section 7000)ofDivi- In SWIMMING TOOL ELECTRIC - t F•EO� stun3 of the Business and Professions Code)or that he is exempt therefrom and VALUATION <� the basis for the alleged exemption. Any violation of Section 7MLS by any OUTLFFs-swITCHEg.TT RES i _ /L /y� applicant fora permit subjectsthe applicant to a civil penalty d not more than `�1 VJ five hundred dollars($50a). - ❑I,asownerofthe property, NEW RFSIDPMIAL ELECTR SQ.FF, STORIES" ,TYPE CONSTRUCTION p perry,or my employees with wages as their sole �7< compensation,wBldotho work andthe structure was intended or°((end for .' ' S�q sale(Sec.7094,Bus4,ess and Profmlons Cade:The Contractofe License Law - � does not apply to an owner dproperty who builds or Improves tbereory and r who doessuchworkhlmsel(orthroughhis own employees,provWedthat such OCC.GROL/la RES.UNITS Improvements are not intended oroffered for sale.If,howevegthe building or - .-TOTAL; improvement b sold within one yearofcompletion,the owner-bu Oder will have L.., ,•„ t„ „t,,�, all �Ir tmllRkurden of proving that he did rust build°rlmpmve for purpose of age.). QTy; {�. "•ALUl1•IBINGPERMIT,.:, ''P '1 'E -FLooD wNE APN j_j L as owner,of the property,am exclusively=trading with licensed PERMIT 155IlANCE meq. rontractonm construct the penject(Sec.7094 Businessand Professions Code • fX/ The Contractor's License Law does nor apply to an owner d property'who ALTER-DRAIN k VENT-WATER(EA) •• Wilde or Improves thereon,and who contracts for such plojern with a `, - C'gBtt admit)licensed pursuant to the Contactors Licmue Law. - '�hI7 �14�`�I'IIFEE,SUMMARY - IJ I am exempt under Sec. B k P C for this reason BACK FLOW PROTECT.DEVICE ' DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N Owner Date - HECEPC p WORKMAN chomp, OMPF1g5ATiON DECLARATION p1X'IVRES PER TRAP SadOOL TAX Y N ❑I htmbcertificate orlwns that I ho mrtulatc of conanm to self4mum,ora RECEIPT N 3800,ateofWorkeri Compensation Insurance oracemfied copytherrnf(Esc. . GAS EA.SYSTEM-1 INCA OUTLETS � PARKFEE Y ' N pulls Isis CJ' ' Cu Y RECEIGAS F.A.SYSTEM-0VER4(EA) DING DIVISION Cam any � ' BUILDING DIVISION FEES �IRed ropy la hereby fumlahed. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK EEE ertltied copy b filed with the city Inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP - PAID' ' Q URA COMPENSATION INSURANCE Q - Ns section need not be completed the SURA is fm SEWER-SAMTARY-STORM EA.MOLT. Date Receitit Porohundred dollars 681 W)or lass') WATER HEATER W/VENT/©.ECTR ENERGY FEB Y N I certify that in the performance of the work forwhich this permit is issued, T I shall not employ any person In any rrunner so as to become subject to the WATEi SYSTGI/TREATING _ Workcrn Compensation laws o(Glifomla. Date PAID Z Z Applicant - - NEW RESIDENTIAL PLmTE SQ.FI. Date Racei tp <a Ina NOTICE TO AI'PLICANT:II after.king this Ceniflate of Exemption,you PO should become subject Rothe Workers'Comperuation provulans°lthe Gbor TOTAL:, N Code,you must forthwith comply with Much pmvlsldns orchis permit shall be 1 W j deemed revoked. _ B I I _ b t CONSTRUCTION LENDING AGENCY SEISMIC FEE a Z 1hereby afOrnn that there ie a construction lending agency for the perform, - TOTAL: ELECTRIC FEE 1 M snot the work which this permit is issued(Sec.3097,Civ.C) 1 V O IendeYS Name l; t,,, $ PLUMBING FEE H. Condor's Address - QTY. , MECHANICAL''PERMIT''i��' �S FEE, LL - MECHANICALFEE co O W I uAllythat l have read this appliatlonand Matethat theabeve Information G Is current.I agree to comply with all city and iountyordlnances and Mate lawn PERMIT ISSUANCE' CO FEES PAID: W relating to building construction,and hereby authorize representatives ofthis F Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt# V agalnst liabilities,judgment., and expenses which may In anywayaccrue AIR FfANDLl UNIT Fro 10,000 CFM) SUBTOTAL: agains�tssdCACAyiinconsejuennre/o.(hee tll9oJiM1s permit. . /tint HANDLING LMT(OVER 10,D10 CFM) CONSTRUCTION TAX - Signature°(Appllant/Contractor Date EYHAusr xooD hV/Dlxn CONSTRUCTION TAX PAID: HAM R DOUS MATERIA LS DISCLOSUR E � r _ occupantWillthe appllcant or future building occupant store or hand in hazardous HEATING UNIT(TO 1(0,000 BTU) 'la(f} Date . Recei tN material as defined by the Cu pertino Municipal Code,Chapter 9.17,and the — - - I— I lealth and Safety Code.,Sectioon 7S53E(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: ❑ Yes [�'IJ Will the appllant orfuturebullding occupant use equipment or devices VFN77LATIONFAN(SINGLE RESID) J$ A ATE which emit harardous air corm minanta as defined by the Bay Area Air city Management Dict 7' BOILER-COMP OI IP OR 1110,000 BTU) f tAQi(Ir Y. f��{r�Nto L K 9A a { a ave read Healthe h a Safety m odea Sections 25555533 and of BOILER-COMP(OVER 100,0!0 BTU) the Californiatand tHealth k Safety Code;Sect1orently h ve a tenant, rid that i 1 understand that if the notify the ing occupant of to currently whicthat Itlsmy NEW RESIDENTIAL MECH. SQ.TT. responsibility Issuance nfa Certificate oftherequlrementswhich mustbemet - �%ta�/ sw`+"tG's""� . .•p� -- r prior to isemnce uta Grtilkaic otOavpanry. z-zi pdtsFflyf�WG�e Owner or.iuthorlud agent - Date - TOTALISSUED0 :' a OFFICE COPY