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21963 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY Building Pro en Ideml(Icatlon PERMIT NO. Building Address: 21963 sera ams: e; . '-1 — g CITY OF CUPERTINO-BUILDING DIVISION —q'� cemrant .me: ueNo: APPLICATION I PERMIT BNLDINGELECTRICAT-MUMBINC-MECHANICAL CATEGORY CONTROL Y Arctitm/Engineer. Lk.No: , QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Addma: PERMRISSUANCE ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION IMreby SeLtIohmthafDimscm3ofthe ur msandPmfe am,r9(e and ATM1'LIANCESRESIDENfIAL _n tOpD r Inense I.M1un force anDlvifect. (The Businnsand Pro(eWmsCode,and my license Is In ni (oro:and effect. PANQS ' Llano C6®- Lk.Ycorr� 1 Date CL`c`# or_ UP TO 2DILAMPS ARCHITECPS DECLARATION 201-10DOAMPS ' q�q�uu coO zzC I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA 5/SQ.FT. k�u Gcnnxd Professional SIGNSELECTRICAL , ��6 OWNER-BUILDER DECLARATION SPECIALCIRCIRT/MIISC z.�R; I hereby afgrmthatlameaemptfrom the Contractor's License Law for the 09o qqqq following reason.(Section 70'11.5,Business and Professions Code:Any city or -, county which requires a permit to construct,alter,Improve,demolish,orrepair TEMPMETER ORPOLE INST. S5 an yotmmmpdortolbi ame,atsorequimtheappHuntfw.uchpemdtto POWER DEVICES 15 1 Rla a signed Yatensom that he is llmssed pursuant to the provisions of the 4613 u,II.. Contractors Lica.law(CMpter 9(commencing with Section 7000).f Divi- SWIMMING IDOL ELECTRIC �O;J Mon3ofthe Busi uses dPa.WmCode)orthathebemmptthemfmmand VALUATION 6.•,577 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWRCHFSFM7VRES applicant for a permit subjectsthe applicant to a civil penalty of not more than five F11,aso nWlarshepr. NEW RESIDENTIAL ELFGER SQFI. ES TYPECONSTRUCTION �n ❑I,as owner of the property,or my employers with wage as tMtr sok compensation,wBBoadnes, workandthe Code:The Intended or offered for doesO oak(See 7014,to as ow and f property Gude:TM C improves License Law �$ who not applytoan owner ofpropertywhobuildsor Improvesthercoryand ^ whodceseuchworkhimself orthrough hlsownemployees,provided that such OCC.GROIIP RLS.UNITS improvements are not Intended oroffered forsale.I(however,lhebulidlog or TOTAL: Improvement lasold within omyearofcompletion,tM owner-builderwill have flic.Ilarden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD TONE APN Lj 4 se owner of the Property,am exclusively contracting with licensed PERMIT ISSUANCE contnctm to mmtmct the project(Sec 7044,Business and Profmbm Code: The Commences License Law dm net apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) Wilde or improves therms,and who contracts for such pkajem with a FEE SUMMARY o7agacior(s)IkmctLimo ds To rauant to the Contraoea Llme Law. BACK FLOW PROTECT.DEVICE LJ I am exempt under Sec B k P C for this reams DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_' • Owner Date RECID'IN WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y N ❑I hereby affirm that I have a mrtirute of convent to self-insum,(S • RECEI'T N 380BI.1b C.Worken'Comperoatlonlmura2 oreu copy thertro((Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE RECEIN 350Q lab CJ OCJ Cd PollryY -- CAS EA.SYSTEM-OVER Com any BUILDING DIVISION FEES Camfind copy b hereby fu ed. GREASE/INDUSIRL WASTE INTERCEPTOR PLANC14ECK FEE Certified copy Is filed with the city Inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID COMPENSATION INSURANCE ytiyVER-SAMT•ARY-STORM FA pBFI. Date Recei t# (Thlssectlon need me be completed If the permit la forone hundred dollars (5700)orlcss.) WATER HEATERW/VENT./ELDCTR ENERGYFEE Y N lartifythat lathe pedormnanao(the work forwMch this pemdt is lsaed, I shall not employ any person In any manner n as to become subject to the WATER SYS[FM/TREATING Workeri Compensation Tawe of Califom a.Date PAID Appllunt Zthis NEW Rmorxnnt PLMe, sDFr. Date Recel t# 0 NOulCETO APPLICANT. fte� Certs,pro ofExemption,oftie Labor Code, become forth to the Workers'such proalonprovbiomomits Lab or TOTAL: N deemed cket(rrthwlth comply with such provisions orthb perMtshell be 1 G deemed revoked. FEE F3 CONSTRUCTION LENDING AGENCY - SEISMIC FEE Z IherebyafOrm that there is a construction lending agency forthe perform- TOTAL; r 1 �T}y�� ELECTRIC FEE O arm of the workfor which this permit b kssued(Sec.3097,CIv.C.) `� .(') Lenders Name PLUMBING FEE 1- Lender's Addrosa QTY, MECHANICAL PERMIT ITE MECHANICAL FEE U I artlfythat l have madthiseppliution and Yatethatthe above lnfomatlon W o ccrecn l agmeto complywith all city and county ordinances and Yate lawn PERMEr ISSUANCE FEES PAID: IL relating to building construction,and hereby authorize representatives of this N citytoenter upan the above-mentbmd property fce Inspection purposes. ALTERORADDTOMECFL ? (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Recei t# against liabilities,judgmands,mYsand expenses which may lnanywayamme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: against ald Cnv In mnpacryence of the granting of this permit AIR HANDLING UNIT(OVER IQ000CIM) CONSTRUCTION TAX Signature of AppRmnt/Contractr DaF)(FIAlJST HOOD r ` �oF 1 ' ' '+ CONSTRUCTION TAX PAID: te HAZARDOUS MATERIALS DISCLOSURE Will theappuanl or future building occupant store or handle hazardous HEATING UNIT(TO 100,OID BTTA Date - Recei t# material as defined by the Cupertino Municipal Cade,Chapter 9,12,and the D Hee lth and Safety Code Ion 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:' ❑Yes Willits hazardu mrebuilding ocmpandby tequipment he Bay Area devices VENTILATION FAN(SINGLE RE4D) ISSjJ-A'R'IaM�IIYR'afiTEtl'F' which emit hazardous ntaminante as defined by the Bay Area Air "Qu❑ality Managemrent District? BORER-COMP OHPOR 100,000 BTU) APR � .f1 Yn No - have read lheh malerlals requirements under Chapter 6.95 of BORER-COMP(OVER 100,000 BM ` 'the California Health&'Safety Code,Sao loss 75505,15533 and 25530.[ �rt� understand that if the building does not currently have a tenant,that it la my NEW REST DENTIAL MEIN. SQFT ��•� mponsibility to notify the occupant of the requirements which most be met prior to issuance M a Certificate of Occupancy. II �, � 3 d6-91 Owner or aulh dagent Data - ISS •D TOTAL: OFFICE COPY