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21628 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Prate(1 Identification PEM]TNO. Building Address: 21628 " V orE Por© n ar 2 8 sone: one. APPLICA A A1/C `uC Tr 1#1Ca- CITY OF CUPERTINO-BUILDING DIVISION Cnn .Nan : ue.N°: APPLICATION /PERMIT1 - 3 trato •O N QV G r BUILDING-ELECTRICALPLUMBINGMECIIAMCAL CATEGORY CONTROL X ORW' Arehltet/Engineer. _ LIc.No: le QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO IT 2— I PLUMB lul�" Address: PERMITISSUANCE �'I 1:1 1:1 11LICENSED CONTRACTOR'S DECLARATION �J I M1ereby'etion 70 that 0)of ivisionsedunder usince LNonsa(Chaparr ssions9deand c APPLIANCESRESIDENML J08 DFSCRETfON lline..hSection force a(d efsion3ofthe Businessand ProfesslomCode,and my icense lain full force and Bred. PANELS License Class LIc.N Date Contractor ARCHITECTS DECLARATION 201-1000 AMTS Q 2 I understand my plans shall be used ss public records. OVERI000AMPS SQ.FT.BOOR AREA S/SQ.FT. qq�± OC E (9 Licensed Professional SIGNS ELECTRICAL <G OWNER-BUILDER DECLARATION SPEC - h'�G Ihereby affirm thatl am exemptfrom the Conlrator'e License law for the CEtCU1T/MLSC following reason.(Section 70315,Business and professions Code:Any city or O I:. TEMP. OR POLE[NST. FAQ 7 F) I Iq cwntywhich requlroaperMttomnstrud,alter,bnpmve,dertnlbh,or repair qy anyatructure prlorto its issuance,also requleesthe applicant for such permit to ['OWERD CES! , 1 Il jt Ei a0 file a signed statement that he is licensed pursuant to the provisions of theit -POOL- \ ELECTRIC Contractors �iLicerselaw(Clo er9(commandn with Section 7000)o(Divi- SWIMVALUATION SOS sion3o(lheeusl ,,,,,d�rofesl ,CMel,,th,lh,l,,,th,ml,,,I MING — A D the Gash for the alleged exemption. Any violation of Se tion 70315 by any O� 7S­gysg3A V a o D <��J apphmntforapemutsub*a theappecanttoadvilperultyo(ntmorethan 0�c five hundred dollars(4500). NEWRFSIDENTIALELECIR SOFT'. STOW =CONSTRUCTION < ❑I,as owner of the property,or my employees with wages as their sok compensation will dothe work.and the structure ls not Intended or offered for a ❑ sale(Sec.7066,Buslessand Professions Cude:The Contractors Limme Law G]$$ does not apply to an owner of property who builds orimprovesthereon,and OCC.GROUP RFS.UNITS who docs such work himself orthrough Ms own employees,provided that such Improvements are not Intended oroffered for sale.H,however thebuilding or TOTAL: Improvement bsoldwithtn oneyearofcompltion,the owner-bullderwill have lhekurden of proving that M did one Wild or Improve for purpose ofsakJ. QTY. PLUMBING PERMIT FEE FLOODZONE APN u 1,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE contractors to construct the project(Sec.7016,Business and Professions Code: The Conindors License Law does not apply to an owner of property who Wilda or Improves thereon,and who comrade for such projets with a ALTER-DRAIN&VENT-WA'TER(EM c tt[ator(s)limnsedpunuanttothe ContndMs License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY LJ I am exempt under Sen B&P C for this reason o FEES DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_ Owner Date RECEIPT N WORK MAN I have.COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y_ N_ ❑I hereby affirm that I have a certificate of consent to self-Insure,or a RFLEBT X certificate of Workers'Compersatlonlmorance or a certified copythemo((Sec. GAS EA.SYSTEM-1 WCAOUTLETS PARK FEE Y N 3800,lab C.) RECEIPTNX Policy X GAF.EA.SYSTEM-OVER 6(EA) BUILDING DIVISION FEES company I ICeyOed copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE �) Gifted copy Is filed with the City Inspection division. S Z(. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recei t# (Ihissetlon need not becompleted If the permit ls forom hundred dollars est°°)ar lev.> WATER PffATFR wrvFxr/FT-EerR ENERGY FEE Y_ N_ I certify that in the performance of the work for which this permit is Issued, I shall not employ any person in any manner so as to become who to the WATEl25YSTEM/TREATING Workers'Compensation Laws of California.Date PAID O Z Applicant NEW RESIDENTIALP MB._9Q.FT. Date Remi t# Z O NOTICE TO APPLICANT.If,ofter making this Certificate of Exemption,you H N should become subject to the Workers'Compemsatlon provisions of the Labor TOTAL: Coale,you must forthwith comply with such provisions orthis permit shall be BUILDING FEE Wj deemed revoked.CONSTRUCTION LENDING AGENCY SEISMIC FEE CL o Ihereby affirmthat there la a construction lending agency for the perform TOTAL, ELECTRIC FEE 7 Z arm of the work for which this permit is Issued(Sec.3097,Civ.CJ U O Lender,Name PLUMBING FEE LL F Lcodcra Address QTY. MECHANI go P FEE MECHANICAL FEE OW Icedf(ylhatl havereadthbapplicationand statethatNeabovefnformettion M is comet.I agree to comply with all city and county ordinances and gate laws PFRMRLSSUANCE FEES PAID: >. relating to building constructim and hereby authorize representatives mfthis F Z city to enter upon the above-mentioned property for inspection purposes. ALTFRORADDTOMECH. (We)agree to save,indemnify an d keep harness the CI of Cupertino Date Receipt# es,ends against liabilities,judgments, and expenses which ma nywayaccme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: against said Cityin con ence of the gra ng of th it. AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX 'ignatumof Applicant ontractmr Date EXHAUST HOOD M/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle huardous HFATINGUMT(TCIWD00BTU) Date Recei t# material a3 defined by the Cupertino Municipal Code,Chapter 9.12,and the Hcalthand Ssf"Cde Sed1on25532(a)? HEATING UNIT(OVER 100,0M BTU) TOTAL: s F-1Yet �)No Wit)the applicant or future building occupant useequipment ordcvicxx VENTILATION FAN(SINGLE RESID) ISSJ.[Ar1�DATE which emit lut.rdom air contaminantsas dented by the Bay Area Air ISS," AG;'[-�1�7 Quality Management District? BOILER-CAMP OHPOR 10B"BTU) _ Yes I�nuINo q 4havcreatlthe h ar[s No materials rcqulrcm nbunder Cha pter6.95o( e0 ER-COMP(OVFRl00,0008 U) I®M b the California Health&Safety Code,Sections 25505,25533 and 25536. 1 JAN„sr understand that lithe Wliding does not currently have a tenant,that it lsmy NEWRFSIDENMALMECH. S'Q.FT. , responsibility to notify the oc,cupant of the miumements which must W met prior to exuance of a Certificate ofOavpancy. Owner or authorised agent Date ISSUED eY'�� TOTAL: OFFICE COPY