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21576 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PERMIT NO. Building Address: -119 21576 caner. one: sine •�W ,Q' CITY OF CUPERTINO-BUILDING DIVISION "° "' LAPPLICATION / PERMIT ✓�� p��p S�a9 BUILDINGELECTRICALPLUMBINGMFLHAMCAL CATEGORY CONTROLM Architect/Engineer. � Lk.No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Addrcsa: ' PERMITISSUANCE ,y ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION I hereby affirmthat l am licensed under provisions of Chapterg(corearmu, APPLIANCESRESIOENTIAL JOB DESCRIPTION ingwith i.ft; 7000).!d effeon3ottheBuelneeeand Pro(esalonsC.de,and my �f��/. license lalnfu _ d i.i.r PANELS �/r( Limn V Lk.N Daf / Contractor /PSO/7,47} Iff!TO ZDO AMPS J Q ARCHITECTS DECLARATION 201-1000 AMPS Z19❑ Li ZO Iunders/and my plain ehaRbe uxd apublic rerords OVER 1000 AMPS .� E(!s� 5/SQ.FT. censed Pro(essimal SIGNS ELECTRICAL {ss(■ 61kg° OWNEReBUILDER DECLARATION SPE �y IN CIALC1RCU1T/MISC 0 7F, a Iherebyaf(Irmihat lamxempt from the Contractor's License Law for the pQq following reason.(Section 7031.5,Business and Professions Code:An city.r FI"'U c°untywhichr°qulrnapermittomrotru",alter,UnpmvgdemiRh,orrcir TEMRMETERORPOLEINSI'. anystmdum prlort°Its Issuance,also requlrestheapplicam for such permit to POWER DEVICES r�E file a signed statement that he is licensed pursuant to the provisions of the Owl� Contractor's Licerx Law(Chapter 9(commencing with Section 7000)of Owl- BOJ sion3ofthe Buslnem.md PrdesslomCWe)orthathebnxempttherefromand SWIMMING POOL ELECTRIC VAIVATION Q.•�77 the basis for the alleged exemption. Any violation°f SMIon 7031.5 by any OUTLE7SSWITCHESFIXTORES � . v�c,J7.,7applicant fora permit subjects the applicant to a civil penalty of not more than Rtundred dollars($SM. NEW RESIDENTIAL ELECTR SQFf. 1,as owner of the property,or my employees with wages as their sole STORIES TYPE CONSTRUCTION compensation,wiR do the work and the structure isnot Intended or offered for sale(Sec.70K Business and Prnfradom Code:The Contractor's Ltd.law �$ docs not apply to an owner of property who builds or improves thereon,and 000.GROUP RFS.UNITS who does such work himself mthrough his own employees,provided that such Improvements are not Intended oroflercd for sale.If,however,thebuilding or TOTAL: i provementbeold wlthinoneyeerofcompletion,the owner-builderwlll have tll0lIuden of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOODZDNR APN LJ L as owner of the property,am exclusively conlrading with'a-.— pptMIT ISSUANCE rontnctors to mreteu"the project(Sec.7014,Business and Profeseloru Code: The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN A VFNf-WATER(EA) Wilde .r Improve.thereon, and who contracts for such p(ojects with a %0(pdor(.)Boded pursuant to the Contractor's Uceme Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY L j I am exempt under Sec. B k P C for this reasonto�Tc..11 once Owner Date DRAINS FLOOR ROOF,AREA,COND, SANITARY Y— N_ WORKMAN COMPENSATION DECLARATION RECTI'N `❑I hereby affirm that I have a certificate of consent to self-Insure,or a FIXTURES PER TRAP SCHOOLTAX Y N_ certificate o(Worken'Comperwtlonlruurann oramrtifled ropy thereo((Sec. RECRUITM 3800,IAb C') GAS FA.SYSfF.M-i INC4 OUTLETS PARK FEE Y_ N PolkyN L41CaQ /07PO3 GAS EA. RECEIP N Cam anv //L 6Rd le—a BUILDING DI VI SI ON FE ES MCertified copy ts hereby te Myeef(Iied copy V Iliad withh the city inspection division.- GRFASE/INDUSriL WASTE INTERCEPTOR PLANCHECK FEE y CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION cm INSURANCE SEWER-SAMTARY-S ORM EA.200FT, Date RCOeI tM ffhorsection need nut W completed I(the permit ts(Drone hundred dollars P ($]00)Icrify that WATER HEATER W/VENT/FI TR ENERGYFEE Y N Imrtay that In the pedonnanm°(the work l.rwhkhthls permit I.Word, — I shall not employ any peaon In any manner at as to become abjad to the Workers Compensation Iawe.(GWATER SYSTEM/TREATING llfornla.Date PAID 0 Z Applicant Date fiscal tN Z O NOTICE TO APPLICANT:]Laher making this Certificate.(Exemption,you NEW RESIDENTIAL PLMB. SQ.FT. Hshould be...ubjed to the Workers'Compensation provisions of the Labor TOTAL: jr N Code,you most forthwith romplywith such provialom.r this permitshall be LU G deemed revoked. BUILDING CL CONSTRUCTION LENDING AGENCY SEISMIC FEE I hereby affirhat them Is a ro®trvction lending agency for the perform- M Z once of the work!m permit which this pedt issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE 00 I.e.der.Name PLUMBING FEE LL l— Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE W Ian ify that l have mad this application and pate that the above ln(.mvtion urorred.I agereto comply with all city and county ordinances and gate lam PERMIT ISSUANCE FEES PAID,. } C relaling to building rorutmction,and hereby authorize rcpresenmtivn of this (— N city to enter upon the abovcmentlomd property for bupedlon purposes. ALTE20RADDTOMECH. Z Date Recei tM — 6V agree to save,Indemnify and keep harmless the ..t y sy..Cupertino P agai bllltlee,'+dgments,mdsand expene vhkh may In any wayaccme AIR HANDLING IIMT(T010,000 CPM) SUBTOTAL: agai Id City l�roma he gr of this permit. q AIR HANDLING UNIT(OVER IO,00)CFM) CONSTRUCTION TAX Sig tum.f Applicant/Contract r Data EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building eccupantstore or handle hazardous HFATINGUMT(TOIW,0D0BTU) Date ated.l..defined by the Cupertino Municipal Code,Chapter 9.12,and the _ RC"' tN m Health and Safety Code 25532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTA : Lt ❑Yes No Will the appllmm or future Wilding occupant use equipment or devices VENrIUTION FAN(SINGLE RESID) ISSUANCE DATE which emit havrdous aircontambu sasde0 d bythe Bay Area Air Qual ty Management DbM BOILER-COMP OHP OR 100,000 BTV) Ry"p y' 0 1{ re read the hazar ...materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) nv Ilifomle I fezlth A Safety Code,Sectlor675 25533 and 75536.1 �..ak lift Wilding does notro ave a ten ant,that It is my NEW RESIDENTIAL MECH. SQ.FT. n b M lty onat lfy the° a ofthe Ircmentswhichmustbemct p os of a roP S- 146 ner or authorized agent Data TOTAL: ISSUED OFFICE COPY