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21797 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification 7 17I'ERMITNO. Buuding Address: O O ' LAD^O 21797 wn nr•. V—+ one: A . CITY OF CUPERTINO-BUILDING DIVISION Contractrr's Name: Lic.No: APPLICATION if PERMIT ��""f % BNLDINGELECTRICALI'LUMBINGMECFiAMCAl CALORY CO O. f )p Archlt /Engineer Lk.Nox If7�J QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: PERMITISSUANCE FV ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION I hereby affirm that l am Beensed under provisions of Chapter9(commum APP11ANCESRFSIDENPfAL JOB DFSCRR'TION ingwith Becton 7000)of DivMon3ofthe9uMnemand Pmfes sCode,and my license Is In full force and effect. PANELS License Class LIC.N pons Q. Date Contractor —UP TO 200 AMPS ARCHITECTS DECLARATION 201-1000A.MPS ce2 I understand my plans shag be used as public records OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT. 0 0 O SIGNS ELECTRICAL Licensed Profeaiovl <<w OWNER-BUILDER DECLARATION In (R SPECIAL CIRCUIT/M1SC L., owing af0rmthat ction7 l.S,Buempt sintheess Contraand License Lw fort he 7 0 G counting reason.(Seaton rmmLo Business and Pmfessl e, Code:Any sty it Fc TEMP.METER OR POLE INST. 54 county which rcqulrcsa permiltoconstaa,sites improve,demoLLsh,or repair any structure prior to its Issuance,alas requires the applicant for such permit to ROWER DEVICES ©� file a signed statement that he Is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Dist- SWUMMINGPOOLELECTRIC VALUATION O sion3 ofthe BusineamdPr mlom Code)orthathe Lsexem therefmmand the bash for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWITCHRS-FIXTURES �3 QQ Q applicant fora permit subjects the applicant to a civil penalty of net room than O five hundred dollar(5500). [:]I.as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION e7� mmpmaation,wllldolhework andthestrusure boot Intended or offered for 5 saleSZ17'0Ny Business and Pretensions Code:The Contudoes License Law I�$ does not apply to an owner of property,who builds or Improves therms,and OCC.CROUP RES.UNITS E whodoessuchworkhimseeorthrwgh hisownemployeeq provided thatsuch Improvements are not intended craffered for sale.l(howevegthebulldingor TOTAL: improvement is sold within ane year ofcompletlon,the owner-budderwill have tlg„pamen of proving that he dm net wild or improve for purpose ofsak.). QTY. PLUMBING PERMIT FEE FLOOD WNE APN "C as owner of the property,am exclusively contracting with licensed PERMITISSUANCE contactors to construct the project(Sec.70K Business and Professions Code: TTu Contnaoes License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER MA) builds or improves thereon, and who contracts for such pRo*m with a FEE SUMMARY cgWTaetorte)licensed Forecast m the Contractor's License Law. gA 71 DMC F- IN 111 am exempt under Sec. B &P C for this rc _ FLES Owner Dam ams DRAINS- R RGOP,ARTA l ND. — SANITARY Y N— F, WORKMAN COMPENSATION DECLARATION 11. FIXNRF_S TRAP, . . SCITOOL TAX Y_ N_ QI hereby af(Irm that I have•certiBate of consent m we-loam,or 1 RECEPT N certiRate o(Workers'Compewtlenlnsurance ce a certifkd copy thereof fliec. GAS EA.SYSTEM-IdNGN OUTLETS 7 FEE Y N_ 3800,lab CJ --�N RF-CEu'1'N I'ollryp GAS .SYSTEM;OVER6(EA) BUILDING DIVISION FEES Com any _ �CeHgiedmpyl,ffl hereby furnisdtyhed. - GREASEANDUSIRL WASTE INTERCEPTOR PLANCHECK FEE �Certeled ropy V feed with the city Inspection divlslon. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID 1^� o COMPENSATION INSURANCE SEWER-SANITARY-STORM F.A.200FT. Dale Receip[# L Jrr L S (this section need not W completed If the permit la future hundred dollar (S1 W)or lea.) WATER HFAlTR W/VFM/ELECTR ENERGY FEE Y_ N_ I certify that In the performance of the work forwhlch this permit Is Issued, 1 shall not employ any person In any manner m as to become subject to the WATER SYSTEM/TREATING Worker%Compensationlawsof Callforola.Data PAID O Z Applicant NEW RESIDENTIAL PLMR. SQ T. Date Re Cl f# P:Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should become sub)ct to the Workers'Compensatlon provisions of the Labor TOTAL: CC N Code,you trust forthwith comply with such provisions or this permit shall be ' Wm j deemed revoked. INC 'E tl90 W — CONSTRUCTION LENDING AGENCY SEISMIC FEE O CL Ihercby a(llrm that there is a construction lending agency forthe perform TOTAL: ELECTRIC FEE Z anceis Ls ofthe work for which this permit sued(Sec.3097,Civ.Q OO Lendcr'e Name PLUMBING FEE F Lenders Addmca QTY. MECHANICAL PERMIT FEE O W I cenilythat l have read this application and statethatthe above Information MECHANICAL FEE 1 Iscormet.l agree to comply with all city and county ordinances and pate laws PERMITISSUANCE FEES PAID: relating to building construction,and hereby authome,representatives of this F W city to enter upon the above-mentioned property for Inspection purposss. ALTERORADDTOMECH. Z (We)agree to ave,indemnityan d keep harmless the City of Cupertino Date Receipt# O against liabilities,jrdgirews,miss and expenses which may in anywayacaue AIRHANDLINGUMT(TO1%"CFM) SUBTOTAL: againstsal ty I.c'oresquencea he granting of apemNt AICONSTRUCTION TAX p^ R HAND[ANG UNTf(OVER 10,MCF.N7 'igna of Applicant/Contractor Date EXHAUST HOOD M/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or suture building occupant store or handle hazardous PLEATING UNIT(TO IDg0000TU) Date Recei t# material as defined by the Cupertino Municipal Coda Chapter 9.17,and the I ealth and Safety Code Salon 2S932(a)? HEATING UNIT(OVER 100,000 BTU) F-IYn MNo Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE BESIDE I$$U TE which emit hacardous air contaminants as defined by the Bay Area Air FED 1 199 Quality Management District? BOILER-COMP DEE'OR 100,00)BTUI ❑Yes ❑No (have read the hazardous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) the Glifornia Health&Safety Code,Sections 25505,75533 and 75536. 1 .y understand that if the building does not currently have a tenant,that it Is my NEW RESIDENTIAL MECid. SQ.FT p•sNN(� responsibility,to notify the occupant of the requiremcnls which must be met prior to lavncc ole Certifate o(Occvpanry. (\ ,\�4J\ Owner or authorized agent Data ISSUED BY.— TOTAL: OFFICE COPY