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21110 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY 407-10 Building Project Identification u PFRMITNO. Building Address: L+G3 21110 03s Vola U � 10 anon axes; on<: A H�}RA' ,J t G--Q.Ql1P CITY OF CUPERTINO-BUILDING DIVISION I� BUI cont �N [- OhbaayaSh; ;� i` I APPLICATION /PERMIT - m�dg�t � pee J LDINGELECTRIGLPLIJMBINC-MLCIIAMCAL CATEGORY CONTROL N A R LN G Ne. QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: PERhETI55UANCE F1 00 LDia LICENSED CONTRQDECLARATION t?]S FfN�®W 1t .. LL LE I hereby affirm that lam Bcnsel under prwLof Cha plot 9 APPLIANCES-RESIDENTIAL JOB DESCRIPTION IngwthSectIon70W)olDivelon3ofthe8pinand fefMion.Code,andmy Il xInfuW ✓ PANES ceCM t.ei: ie.I onnttorUP TO 20DAK?.S ARCHITECTS DECLARATION 201-IODOAMN ^WWW0 O I understand my phru shall be used m public reaanlc , OVER 1000 AMPS �.FI'.FLOOR AREA S/SQ.FT.' �2rvil y w�j Llmnaed Profeselmul SIGNS ELECTRICAL R c6 g OWNER-BUILDER DECLARATION SPECIALCIRCU1T/NLSC � r z Gd& I herebyafBrenthat lam exempt frmetthe Contradoe.Llnnse iaw for the ZZ b qqqq ( ntyngichrvgfSe aMrnil$Buslnemand Pimp a e=lCode: n cityr ��� founting re on.(Seaion 703tlo roatact,adProfpmvgdemall A orrea t TEMP.METER OR POLE]NST. 14 a anystructure priorlo Its bsuance,alsorequlres theapplicanl forsuch permit to POWER gDEVICES V' file a signed statement that he Is licensed pursuant to the providers of the Ow Cmd.der's License Law(Chapter 9(mmnnncing with Section 7000)of DWI- �0 xion3 oftheBuslnessand PmfesalomCode)orthat he is exempt therefromVALUATIONand SWIMMING POOL ELECTRIC e the basis(or the alleged exemption. Any violation of Section 70315 by any pr5'1 applicant for a permit subjects the applicant to a civil penalty of net more than OUTLETrsSWITGHES-FIXTURES $ five hundred asrowneof thepe. ts NEW RESIDENTIAL ELECTR SQ.FL 5701RIFS ( L TYPE CONSTRUCTION 7�r ❑I,asewar ofothe weerty,or my employ u,noes t withwagesr offereir d fo mmpewtion,wllldothe work endthestacturc lsnoHntended or of(emd for 0 pp O cele(Sec.7094,Business and Professions Code:The Contractor's License Law [;75$ does not apply to an owner of property who bo lids or improves l hereon,and OCC.GROUIa RES.UNITS ❑❑ whodoee such work hlnseBorthrough ldsownemployess,provided that such improvemenbammiH tendedorofferedferule.If,however,thebudldingor TOTAL- Improvement O lasold within omyearofcomplMion,the ownenbu0derwBl have tF,,Iurdenofpmving that he did not build or Improve for purpose ofuleJ. QTY. PLUMBING PERMIT FEE FLOODZDNE APN L„J L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE '2s ..trade.to coatad the project(Sec.7044,goal..and Prnfessoa lCode: The Commences License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA) Wild.or Improves thereon, and who contracts for such ptoktte with a FEE SUMMARY cqp{�+dor(,)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE LJ I am exempt under Sec. B&P C for this reason • OUTSI Dr.FEES Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N Date RECQI'I'N WOR KMAN COMPENSATION DECORATION FDnURES-PER TNM SCHOOL TAX Y N QI hereby af(bm that I t•certificate of consent to op therm,or RFGEIPT N certWcate bC.) ricers Compevatlonlaurancemecertlfled copy thereof(gee GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N Polis Lab C.I Polity N RBCFR"f M C ray CAS V ) BUILDING DIVISION FEES nCertified copy Is hereby furnished. CRF PLANCHECK FEE Certlfled copy b filed with the city inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' G as E PAID pry. COMPENSATION INSURANCE BEWF.R-C��STORM G.2lXIFT. Date RCOCI [N aS.! (fhlssedionneed net becoreplcted ifthe permit bforomhundred dollars -RNRrG a ($100)orless3 WATER HEATER W/VENT/ELCCTR NERGYFEE Y N Icertify that In the performance ofthe,work forwhich this permit b lamed, — . — I shall not employ any person In any manner an as to become subject to the WATER SYSTEM/TREATING Wmkcn'Compenutlon laws of Glifomh.Date PAID 0 Z Applicant NEW RESIDENTIAL PLMB. Dale Recei [# Z O NOTIGETD become ttothe orkerafte, Comping rCilen provisions oft the c"Q'FT• CC Code,you ubjedmthe Workers'Comproviers orthioarmit s Lab or TOTAL: LU W Code, coked.forthwith comply with each provlsloa or this permit shall be N G > deemed revoked. (L p CONSTRUCTION LENDING AGENCY SEISMIC FEE BUIL d CONSTRUCTION I herebyaffirmn that there is a roatmetlon lend ingagerny for the perform ELECTRIC FEE D Z arm ofthework for which this permit la laeued(Sec.3097,CW.C.) .TOTAL: Q U O Krises Name PLUMBING FEE QTY. MECHANICAL PERMIT FEE LL L) Lenders Address tionMECHANICAL FEE A77t T6 O W ]reed,Idg hocomplywith aave mad this licetlondcounand tymeRnarcesein(orts Is" 1 mlatlect.Iagreeto complywlth alndhembyathooseeprcesand gets PERMIT ISSUANCE Z_� FEES PAID: �. W relatl to enter rupont roatactendlon hereby authorize repreaenpurpos o(thb I- Z city(We) agree to the sieve-men/toned property for Wpe cit purposes. ALT�20R ADD TO MECH. Date Recel HI - (We)agree s,ave emnity a d keep h Mesa the Clty y Cupertino P against lbbWt cab,cost dexpb sable mayln any ways AIR HANDLING UNIT DO CFM) SUBTOTAL' s agalat mm�sequen (tM ntin of p<tmlt. et Q AIR HANDLING UNIT(OVER 10,=CFM) CONSTRUCTION TAX gnatureofA ant Contractora EXHAUSTI[OOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISC SUR .s Wllllheappliant orfuture building occupant store or handle haurdous HFATINGUNIT(T0100,000BTU) Date RBCeI tR , as� material as defined by the Cupertino Municipal Code,Chapter 9.17,and the Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 1W000 BTU) TOTAL: T1 Yes M No Ill the appllunt orfuNre bulldingoccvpant use equipment ardevkcs VENTILATION FAN(SINGLE RESID) ISSUANCE DATE which emit hazardous airmntamiantsas defined bythe Bay Area Air _ 9O. • Quality Management District? BOILER-COMP OF B'OR 100,000 BTU)4 Yes No haveread the bazar out materials ecims 25re5,2553cand 2554. 1 of RORER-COMP(OVEIt 100,000 OTU) i JAM NA''991 theCaliforniaHealth&Safety Coes not have.land,that. ] 49 a7 Us71y0 understand that lfth< Ilding does not mrrcntly have alenani that llbmy NEW RESIDENTIAL MECH. SQ.17. i rsspoalbllity to he amp of them men which nasi be rrnt prier to a Certlflcat Oav /V�s!he 22 Fie-a�-Si-q or aur' art a cat Date V F— r'1).-/`s"�'� TOTAL: O ISSUED OY: OFFICE COPY