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21317
is �0 C70C' �EUE1s �naG1 Fula a U k o� �O • I � APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY Building Project Identification BuildAddress: �(D2.o, 'T(�:2 Z 0� PERMIT NO. 21317 peing e ..cm, FromAPPTICAA 1Z-5-2Z°i�J CITY OF CUPERTINO-BUILDING DIVISION APPLICATION I PERMIT BUILDINGEL TRICA4PLUMBINGMFGHANICAL / e•� �� 16-73+ lO Contractors Name: 5y eta Lic.No: CATEGORY CON'IROL�� IY Architect/Engineer. Llc No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFOLD MliLli Address "LOU �1�1 PLUMB © ❑ 11 1:1LICENSED PERMITISSUANCE CONTRACTOR'S DECLARATION thereby affirm Mat lam licensed under provisions na of o(ChChapter9 (commenc Ingwlth&etion7000)of DlWeion3ohhe BuMnessand ProfeeMons Cade,and my Iicense le in full mrcn.nd affect. APPLIANCES -RESIDENTIAL JOB DESCRIPTION PANELS License Class Lic.# Date Contractor UP TO 2DOAhVS 201-1000 AMPS ARCHITECTS DECLARATION [understand my plaruehxU be used as public records, OVER 1000 AMPS SQ. FT. FLOOR AREA $/SQ. FT. SIGNS ELECTRICAL Licensed Professional SPECIAL CIRCUIT/MLSC OWNER -BUILDER DECLARATION I hereby of li mOut I am exempt from the Contractor's License Law for the TEMP. METER OR POLE INST. following reason.(&lion 7031.5, Business and Professions Code: Any city or county which requres a perndtto mrotroci, alter, Improve, demolish, or repair anystructom pdmto its btiance, also requlrestheappllcant forsuch permit to file a signed statement that he is licensed pursuant to the provlsiom of the POWER DEVICES . SWIMMING POOL ELECTRIC 117T.ETSSWITCHESFIXTURES Commerce. License I w(Chapter9(mmnpnMng with Section 7000) of Owl. slap 3 of the Bu siness and Profemioru Code) orthat he is eaempt Nerefrom and the Wats for the alleged exemption. Any violation of Section 7031.5 by any marathon(�j applicant fora permit subjects the applicant to a civil penalty of not marathon VALUATION J 0 s fe•� �•+J five hundred ❑Lowner of thep0). ae owner of the property, or employees with wages there sole RESID AL ELECTR SQ.FT. STORIES TYPECONSTRUCTION compensation, will do the rk, and he e Is of r d for eLaw Businessand Pmfiafam Code: sale (Bac. 7044, Buebsse and Pro(esslanu Code: The Contractors Llcerue Law The Contactor License docs not apply to an owner of property who Wilda or Improves (hereon, and who dose such work himself or l h rou gh his own empl oyees, provided that such Improvements are not Intended oruffered lorsale. If, however, the Wilding or IM i TOTAL: OCC.GROUP RES. UNITS Improvement bwid withlnaneyearofcamplMlon,thcawner-buBderwlllhave eno(provIng thetbedid not Wlld orimprove lar purposeof a. as, owner of the property, am exclusively rnntracting with lice tractors to commas Me project (Sm. 7014 Business and Pmless ms C e: Q GING PERMIT FEE FLOOD TONE APN IT A- E 1s Contnclars License Law does not apply to on owner of property w builds or Improves thereon, sad who contracts, far such pkojeMs with [5actiaeWhemed pursuantto the Contractor's License Law. I am exempt under See B k P C far this rcaaoOUTSI �: [N k VENT- WM ) FEE SUMMARY B WI'ItO.LECLD OF FITS RAINS FLOORR • A • COND. SANITARY Y N RECEIPT Owner Oats, WORKMAN COMPLNSATION DECLARATION ❑I Hereby affirm that I have a cenifiam of canes, m "l inmm, ora cenifiateofWmIcare Camperuatioalvurame ora certlfled ropy ihereo((Sec. 3800, lab C.) Policy # FIXTURES PER TRM SOR)OLTAX Y_ N RECEIPT # GAS F.A. SY -Icj{J OUTLETS PARK FEE Y N ' RECEIPT M Com any GAS EA. S -0VER4(EA) BUILDING DIVISION FEES �CariOed copy b hereby tumbled. ❑CeriRled copy b filed with the city Inspection division. CERTIFICATE OF EREMPIION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit b for ane hundred dollars GREASE/I D LWASTE INTERCEL'TOR PLANCHEC ED D1 t# GREASE SEWER -SAA ARY-STORM F.A. 200FT. WATER HEATELR W/VEM/ELECTR ENERGY 00 ($100)mleu.) l o:nlfy that lathe performance of the work forwhlch this permit is Issued, WATER �,��/TREATING I shall not employ any person m any manner so as to become who to the Workers' Compansztlon Laws of California. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor PAID Date 1 t# tCW NEW RESIDENTIAL PWB. SQ.FT. TOTA BUILDINC FEE00 Code, you at forthwith comply with such provisimu mthb permit shall be deemed revoked. SEISMIC FEE CONSTRUCTION LENDING AGENCY I herebyaftm that them is a construction lending agency for the perform .me of the work for which this permit Is Issued (Sec. 3097, Civ. C.) Lender. Name Lender's Add.. I mnlfythall have ma ithisapplicatlonand Matethat theabovelnformetion bmrrect.I.gree to comply with allcityand rountyaNimactsand slatelaws TOTAL: _ ELECTRIC FEE PLUMBING FEE QTY. MECHANICAL PERMIT FEE MECHANICAL FEE PERMIT ISSUANCE FEES PAID: relating to building construetlon, and hereby authorize representatives althis sty to enter upon the above-mentioned property for inspection purposes. (We) agrom to save, indemnify an d krep harmless the City of Cu pen Ino against liabilities, pdgrPc[,i and expenses which may inaay wayamue ago d ity lama esE o(i granting ofthleperenit. ' f ALTER OR ADDTOMECH. Date ReCel t# AIR HANDLING UNIT( TO 10,000 CFM) SUBTOTAL' AIR HANDLINGUNR(OVER l0,0D0CFM) CONSTRUCCIONTAX Signatureof Appuc UCon actor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: H 2ARDOUS MATERIALS DISCLOSURE HEA FILING UNIT (TO 100,000 BTU) - Will the appllvnt Ifuture building occupant More or handlehazardous imterbl as deflned by the CupeMlno Murdclpal Cade, Chapter 9.12, and the IkalthandSafetyCod lon 25532(a)? ❑ Yes o Will the applicant o future building occupant use equipment ordevices Date RCCCI t# IIEATING UNIT (OVER 100,000 BTU) TOTAL: VENTILATION FAN (SINGLE RESID) ISSUANCE DATE which emit harardous Irmntaminants as defined by the Bay Area Air Quality Marugerrmt District? 4 Yea `�0 have read the havr{ous rraterlals requirements under Chapter 6.95 of the CalBornia Health 4 $safety Code, Sections 25505, 25533 and 25534. I understand that if the building does, not currently have a tenant, that It is my responsibility, to notify the YYat of a re ulremecis which swat be met prior amorceofa CeMtficat o(Dc rp 2a.#dfBlp r 7 �r a la 9� y' a ISSUED BI BOILER -COMP OHP OR 100,DW BTU) BOILER-COMP(OVERIM,000BTU) NEW RESIDENTIAL MECH. SQ.FT. rte orauthoriredagent Date TOTAL: OFFICE COPY