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21613APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY Building Project Identification Building Address to uv -m o©� PERMIT NO. 21613 wnere sore: one: CITY OF CUPERTINO-BUILDING DIVISION � APPLICATION / PERMIT BULDLNGELECTRICALPLUMBING-MECHANICAL A (Core " � G1 Q_». ' LI='N. 1/��''�` 174637 CATEGORY CONTROL. Architect/Engineer. Lk. No: QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO. �r //� Addre,a: , `. � . PERMITISSUANCE ❑ .� ❑ ❑ ! LICENSED CONTRACFOR'S DECLARATION APPLIANCES -RESIDENTIAL PANELS BLIC I herebyeffimrthat l arrikeiaed under provtvlonsa(Chapter9(commaree Section7000)of DiWsion3 o(the Businemand ProfmsionsCode, and my licen in force and effect. 1 463 nae Clam Lkec JOB DESCRIPTIONIngwith - lu�iL/I ate Contractor_GtuAG• IYsta @ Ge ARCHITECTSDE IARATION %.1g, 2014000 AMPS I understand my plain shall be used as public remrde. OVER 1000 AMPS - SQ. Fr. FLOOR AREA 5/SQ. Ff. SIGNSELECTRicAL Licenmd Profemiorul OWNER -BUILDER DECLARATION I hereby afOmithat I am exempt from the Contractor's License Law for the following remon.(SecMon 7031.5, Buelnem and Prolenbne Code; Any city or countywhich requiresa permittoccom tei alter, bnprove, dennlbh,orrepair anyatmdureprbrtoltn issuance,alsorequlreatheapcaliforsuchperentto file a signed statement that he b Ikensed pursuant to the provision, of the Contncmrb License Law (Chapter 9 (commenMg with Section 7000) of Dlvl- sion3 ofthe Business and ProlemioM Code) mthat he bexemptthereho cut the basis for the alleged exemption. Any violationof Se Lion 7031.5 by any' applicant fora permit subjecoethe applicant to a civil penalty of not more than five hundred dollars (5500). F11, as owner of the property; or my employees with wages as their sole compensation, will do the work and the structure is not Intended or offered for rule (Sec 7094, Business and Profeediutel Code: The Contractara License Law SPECLIL C9RCUIT/MISC Tp�(p METER OR POLE INS. ppyVBg DEVICES SWIMMING POOL EL VALUATION ' UTLE•p�g(y(.mHFSFl NEW RESIDENIIAL ELECTR FQ,FL :!, k4 STORIES TYPE CONSTRUCTION v does not apply to an owner of property who Wilds or improves thereon, and who deassuch work himself or through his own employees, provided that such OCC.GROUP RFS.UNUS' improvements are not Intended or offered for sale. If, however, the building or Improvement b sold with in one yearo(compietion, the owner-builderwill have tll,iurden of pmWng that he did not build or improve for purpose of sale.). I as owner or the ro am exclusively ...d ng with licensed u property, to curtainedtheLawproject (Seer mu Code: rf •. TOTAL. 5 QTY, PLUMBINGPERMIT FEE 'PERMIT ISSUANCE 0 . FLOOD 7DNE APN TheconCoors The Contractor's License Law dcea not apply c a f owner of property who apply to an owner pro builds t rdmpravee thereon, and who contracts for such pt,ojecb with a ant Seto the Contractor's License Law. cq�tfacameempt under ' I_I I am exempt under Sec. B & P C for this reason ALTER -DRAIN & VENT - WATER (EA) BACK ROW PROTECT. DEVICE ' FEE SUMMARY Owner Date DRAINS FLOOR ROOF, AREA, COND. - F09'IlJRF_3' PER TRAP SANITARY Y N_ RECEIPT WORIONAN COMPFN5ATION DECLARATION ❑I hereby af(km that I have a certlRcate of rommot to self -Insure, m a SCHOOLTAX Y— N certificate of Workers' Com peruaBonlruurance ora __Ifcopythereof (Sec. 3800, GbC.).J - PoliryN I.CQ9665'S RECEBxf N GAS EA. SYSTEM -1 INC.40UTLET5 PARK FEE Y— N— RECElfrI'p Coma e_-_..lel �rtRied copy Ya hembyth the ed city .C71 CertUied ropy b (Ikd with the city IrupeRbn division. .l,< GAS EA'SYSI-OVER4(EA) GREASE/WDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES PLANCHECK FEE GREASE TRAP CERTIFICATE OF FJ(EMPFION FROM WORKERS' COMPENSATION INSURANCE Rhi section need nct be rompinted If the.scent b (Drone hundred dollar (81I mftlfythin I oy an perseem in an trunner ors to b co permit is issued, ll net employ I,hall not employ any.Leon f any manner at u ro become subject to ti; Workcrs'Compeneatlon Gwe o(CaB(ornb, Date Applicant you NOTICEco become after Workers' to Co perartion leo(E -fthe Labor Code, you Code, you must forthwith comply with such provbloru arlhb permit shall be eforth it the Workers' such praaHonprovbiomrmit s Lab be deerrud revoked. � PAID Date Recel t# SEWER -SANITARY -.STORM EA "Ff . WATER HEATER W/VENT/ELECTR ENERGY FEE Y N— PAID Date Revel t# WATERSYSTEM/TREATING NEW RFSIDENTTAL PLMe. SQ}7,shoul � TOTAL: BUILDING CONSTRUCTION LENDING AGENCY I hereby afBrmthat there b a construction lending agency for the performTOTAL: ante of the work for which this permit Is Issued (Sec. 3097, Civ.Cj Lenders Name 1 SEISMIC FEE ELECTRIC FEE PLUMBING FEE Le Id diAddrem tion state tordina lwth QTY. MECHANICAL PERMIT FEE MECHANICAL FEE � FEES PAID: ' allmtyand c correct. correct. Lgreero complain, alld I agreet comply mate laws cess dmate PERMIT ISSUANCE e hembirountytic capcesand authentic representatives o(thb relating to building rormtm ..and hereby property city W)enter eetosapon the ,bodemnifyanedpropeharrrdimpection Cityof upperoses the City y Cupertino (We) agree to rove, indemnify and keep es which agaWtliabNllee,pdgmenb, coateand expenses which cosy In anywayacaue ago t, City In oasequence o granting of lhb perms A C /tel/�/�na 9 ALTER OR ADD TOMEGH. ,AIR HANDLING UMT(f010,000 CFM) ' Date Recet t# P SUBTOTAL: AIR HANDLING UNIT I0,000CFM) CONSTRUCTION TAX �ignatureor Appucant/Contractor Date 0k IXHAus'r Hoop(W/Duel) CONSTRUCTION TAX PAID: HAZAROOU ITER D SCLOSURE . HEATING UNIT (TO 100,000 BTU) Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the Health and Safety Cade Section 25532(a)2 r7 Yea M No Date Receipt HEATING UNIT(OVER 100,000 BTU _ TOTA Will the applicant or lunette building occupant use equipment or devices which vent hazardous air coneambunts as defined by the Bay Area Air VENTILATION FAN (SINGLE RESID) - I$$ •ATE BOILER -COMP DHP OR 100,000 BTU - Iity Management District? Yea ❑❑ No Q�jshave Q A� � "Lis�At'J�1) BOILER-COMP(OVER 100,000 BTU) read thchazardousmxterialarequiraments underChapter 6.95 of 6 ,1^ the California Health & Safety Code, Sectiore 25505, 25533 and 25534. I NEWRESIDENTIALMECH. SQ.Fr undersea nd that if the building does not currently have a tenant, that it is my responsibility to not By the occupant of the requirements which must be mat u{ 1IRR�E prior to ixsueenre of a Certificate of Occupancy. ISSUED BY:—� T•�1�e�w�.a�G.ty Owner or authorised agent - Data TOTAL: OFFICE COPY