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21853 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PERMIT NO. �BuOding Ad eu re ��p 1218 5 3 n a one: CITY OF CUPERTINQBUILDING DIVISION A:15 A oa I� � APPLICATION /PERMIT ! .- Ar ice En yrS — BUILDING-11 C UCALPLUMBINGMECHAMCAL CATEGORY CONTROL N .NO Lk.No: QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO Addr, 14 PERMITISSUANCE. �1•DO C�) Di DCON ACTOWSDECLARATION IM I am licensed under provlslonsof Chapter 9(cammenc APPLIANCESRESIDENTIAL ]OB DESCRIVI ION I ingwith vlslon3aftheguslnemand Professions Code,and my. G Ilrense l d dit&. PANELS LimDate CHLt.NE� UP TO 200AMPq Plil4'►J'�L•R ��GN Dale Contntlor ARCHITECT 1 701-10110 AMPS p�+MM., Iunderstan myplzru,hallbeu OVER1000AMPS SQ.Ff.FLOOR AREA E/SQ.FT. tt dd`j Lima"Professional SIGNS ELECTRICAL <� OWNER-BUILDER DECLARATION SPECIAL CEiCU1T/MISC ` Iherebya(firm'hat I am exemptlmm the Contractor's License law for the O following reason.(Section 70315,Business and ProfessAny city orions Code:At:,� TEMP.MEPQ4ORPOLEINSf. F5 cauntycam,requbna hussar ,aLsorunireathimprovgdemolbh,orrepalr g le swRureprlortoIts that a Is abo sed pursuant t the pro inionsuch of t e POWER DEVICES file a signed statement that be ti licensed pursuant to the provisions of the w Contractor's License Lw(Chapter9(commencing with Section Divi- VAII TT KI In SWIMNO NG POOL ELECTRIC SOS she hast the the alleged Any ,dation f exempt 70315 by and thebannsfortheallegedexemption. Anyviolationo!S llyo70115byany OUTLET'SSWITCHESFIXTVRES five andforapemdlsubjectatheappacanitoa tlW(penalty of net more Than five hundred donors he pm I,ea owner of the ro NEW RESIDENTIAL ELECIR SQ.Ff. STORIES TYPE CONSTRUCTION ❑ p poky,or my employees with wages their sole 7n, wmpSec.70 ,will do the Business and k,and ssions utlureti notIntendedor License exi for Law O sale(Sec.7044,to an df property Code:The Controfimp eves harem law $� doss not spplyuch torn owner offprough hisobuilds nemporimproovided that such OCC.GROUP RFS.UNRS who does mchwork hlmseBorthmugh hleown employee,,provided lhatmch lmprovem.tsarenotlntendedoro(feredforule.Il,howevegthebulldingor TOTAL: /9 Sa improvement bsold withinoneyearofcampletlo,theowner-bullderwill have tflgjlurden of proving that he did not build or Improve for purpose o(aale.). QTY. PLUMBING PERMIT FEE FLOOD TpNE ApN u1,as owner of the propeky,am exclusively contracting with licensed PERMIT ISSUANCE contractors to canalruct the project(Sec.7054,Business and Professions Code: The Contractor's License Law docs not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) Wilds or improves thereon, and who contracts far such pkojecre with a M darts)licensed pursuant to the Conlrakor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY LJ I am exempt under Sec. B&P C for this reasonQI)TqI 11P Owner Date DRAINS-FLOOR ROOF,AREA,COND. SANITARY Y N RECF3Pf p WORKMAN COMPENSATION DECLARATION S(�li L X Y N ❑I hereby affirm That I have a certificate of consent to self-Insure,ora FIXTURES PER THAI-AI- I l` cekifiuleafWo ke 'Comps once only ranoracertifdkcapythereof(Sec. t RECEIPT N 3800,Iab GAS PA.SY C4D[flLEf� PARK FEE I Y N Polley N se _ -' t RECEIPT N GAS ER 4 EA.SYSTEM-OV (EAJ �Cam any �� L BUILDING DIVISIONFEES Cele c p ed. W EPTOR C 'CK FEE ertified copy ti filed with the city inspection division. GREASE/INDUS CERTIFICATE OF EXEM PFION FROM WOR KERS' GREASE TRAk PAID COMPENSATION INSURANCE SEWER SA _ RM EAyXIOFT Date Reed [q L 3 Cfhis sectlon need not becompleted Bthe permit ti/orom hundred dollars (5100)orlcss3 WATER w/vENT/©.ECTR ENERGY FEE Y N Icertify that In the performance afthe work forwhich this permit is Issued, — I shall not employ any person In any manner so as to became subject to the WA STEM/TREATING Workers'Compenution Laws of Callfomla.Date PAID Z Z Applicant RESIDENTIAL PLMB. SQFr. Date Reeel til O NOT(CEcame TO subject tothe,cher rs'Com a cationCerflirovisons oft the should became to the ply with Camprovisins orthioruomits Lab or TOTAL: LU N Cod,drevoletforthwith comply with such provisions arthV permit shall be BUILDING rO� W deemed revoked. ao CONSTRUCTIONLENDING AGENCY SEISMIC FEE O I hereby affirm that(hereemIsb aa construction Iandingagency,for the perform ELECTRIC FEE Z anceo(1.ework forwNchthis rnotis LLmed CIv.C.) TOTAL: V O lender,Name 1 n� PLUMBING FEE LL — Leader'sAd e9—^—h�11` QTY. MECHANICAL PERMIT FEE MECHANICAL FEE OW I cekifythat l have read this ap Bution and statethat Neabove Information 1 iscarrect.Iagreelo comply with all cityand county ordinances and state law, PERMIT ISSUANCE FEES PAID: >_ N relating to building rovlruRlon,and hereby authorae representatives ofthis H U) city,to enter upon the abownonatloned property for inspection P' ALTERORADD'IOMFCH. - ate Recei tN V — (We)wto nml an d keep harmless the C o agaires dexpen,eswhlchmayl AIR HANDLING UNIT(TO 10,0D)CFM) SUBTOTAL: agar , t Ing ofstirPe It. AIR HANDLING UNIT(OVER IOOW CFM CONSTRUCTION TAX rca o - DataEXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: OUS MATERIALS DISCLOSURE Will teappcanor future building occupant store or handle hazardous HEATING UNIT(TO 100,000 material as de0ood by the Cupertino Municipal Code,Chapter 9.17,and the — _ Date RCCeI IN HmIthand Safety Cade Section 25537(a)7 HEATING UNIT(OVER BTU) TOTAL: ❑Yea No Will the applicant or ture building occupant use equipment or devices VENTILATION FA INGLERESID) ISSUANCE DTE which emit havrdous air contaminants as defined by the Bay Area Air Quality Management DlstktlT BOILER-COM HPOA 100,000 BTI)) Yea (�No F 1 ? If have read the hax'Sou,materials requirements der Chapter 6.95 of BOILER- MP(OVER 100,000 BIIq p the Call ornla Health&Safety Cad,State.25SOS,25533 and 75534, 1 R understand that lithe building dace not currently have a tenant,that It is my NEW/FSIDGNTTAL MECH. SQ.IT. resporeiblllly,to Ratify the occupant of the requirements which must be met prior to issuance of a Certificate of Occupancy. ri1u of cu �*nn Owner or aulhodved agent Date n, P`^ TOTAL: ISSUEDBY: OFFICE COPY