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21026 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PERMIT NO. Building Address: 21026 � C� C:o� 96-0l era are COhh% 2 44 -�68gA A CITY OF CUPERTTNO-BUILDING DIVISION c°^o-aeor.wme: LIc.N°: APPLICATION / PERMIT �•^ 6� r ArehbM/Engineer. Lic.N. �Lqq BUILDINGELECTRICALPLUMBING- E HAMCAL CATEGORY CONTROtgz QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO Address PERMITISSUANCE ❑ ❑ E:1LICENSED CONTRACTOR'S DECLARATION I hereby affirm that l am licensed under provisions of Chapter 9(mmmenc APPLIANCES RESIDENTIAL JOB DESCRIPTION Ingwlth Section7000)of Dlvbin3 ofthe Buslnessand ProfensionaCode,and my license Is In full force and effect. PANELS License Class L Date Contractor UP TO 2DO ANTS ARCHITECT'S DECLARATION 201-]000AMM rc Z I understand my plans,hall be used as public records. JOVER IWO AMPS SQ.FT.FLOOR AREA $/SQ.FT. O X� Licensed Professional SIGNS ELECTRICAL OWNER-BUILDER DECLARATION SPECIAL CIRCNT/MLSC L., Ihereby affirm that am exempt from the Contractor's License Law for the FO 70..qqqqq��y following reason.(Section 7mi.5,Business and PmfsaAom Code:Any city or ZS3 county which requires permit tocommoct,alter,improve,demolish,orrepair TEMP.MEEK OR POLE INS]. �a°.J any structure prlorm its Issuance,also requlresthe applicant forsuch permit to Oilk a signed statement that he is licensed pursuant to the provisions of the pOlygg DEVICES Contractor's License Law with Section 7000)of 8Divi- SWIMMING POOL ELECTRIC ao� sl°n3oftheBusnessandPrefenl°mCode)orthatheItexempttherefromand VALUATION a S^S the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS9r4TCHESFIXFURIS aa: applla foray rmitaubectsthe applicant tootivilpemltyo no more than _ five h dyed dollars(5,500). NEW RESID �E TR . ,as owner of the property,or my employees with wages as their sole �'M1T' Oq PECONSIRUCTION C < mmpensation,wBldotMw rkandthestmmm boot intended or offered for ❑ sale(Sec.7W41,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or Improves thereon,andS.UNITSwhodonsuch w°rkhimself orthmugh hisownemployees,provided that suchimprovements are notIntended oroffered forsae.If,however,thebullding or DAIS TOTAL:mprove ntbsoldwithinoneyearofcompletiomtheowner-budderwlllluve ofpmvingthathedld not build or improve for purpose ofsaleJ. QTY. PL GPERMIT FEE " L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE contractors to construct the project(Sec.7016,Business and Professions Code: The Contractors License Law don not apply to an owner M property who ALTER-DRAIN&VEM-WATER(Ell) bu Bov ds or Impres thereo , and who contracts for such pW)a a with a cq[Ltractor(a conned pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY LJ I am exempt under Seg. B&P C for this reason 7, — OUTSIDE FETS OwnerADat ��Fr DRAINS.FLOCK ROOF,AREA,GOND. SANITARY Y_ N_ 3V KMN COM SATION DECLAR ION / BE=# 01 hereby affirm that I have a mrtlficate of consent to self-nvre,or a FD( �s TPER TRAP SCHOOLTAX Y_ N certifiam of Wmken'Compensation Insurance ora certified copy thereof(Sec. RECEIPT'N 3800,Lab C.) GAS EA.SYSTEM-1 INCAOUILETS PARK FEE Y N Policy N RECEIPT N Com any GAS FA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES ffCcrtified ropy b hereby furnished. ❑Cettified copy is filed with the city inspection division. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE I CERTIFICATE OF IXEMPFION FROM WORKERS' GRFASE7AAP PAID COMPENSATION INSURANCE SEWERSAMTARYSTORM F.A.200FT Date Recel t# (Ihbtectnn need nes be completed lithe permit b!carom hundred dollen 6100)or Immid th WATER HEATER W/VENT/ELECTR ENERGYFEE Y N ]certify that tithe performance ofthework forwhlch this pertNtbIssued, — I shall not employ any person in any manner no as to becorre subjea to the WATER SYSTEM/TREATING wurkers'C°mpematnn Lawaorf Cahfornia.Date PAID Z NOTICE rat after NEW RESIDENTIAL PLMB. Z O N0710ETOAPPLje&to eWorkeraking s'Com er ationiateof Exemption,Labor ��FI'. Date RTA [# H should ode,yo =a aurthwit the ply with such provisinprovhis permit s Gbor TOTAL: W rimmed rmstlmlhwith comply with euchprovisiom orthB pemNt shall be W > deemed revoked. BUILDING FEE CL ° Iherebyafirm that themhes construcION t niNG entlng agency for the perform SEISMIC FEE O Z ancooftheworkforwhichthbpermit boneed(Sec.3097,Cle.C3 TOTAL: ELECTRIC FEE (� O lender's Name PLUMBING FEE IL LendersAddrea QTY. MECHANICAL PERMIT FEB MECHANICAL FEE O W Icetlilythatlhave read thbapplicatlonand sta(ethattM1e Anwamformatlon 1 is correct.Iagree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID: >. fn relating tobeilaingcomtructlon,and hereby authorim repressmativesofthe, F Z City to enter upon the above-mentioned property for Inspection purported. ALTERORADDTOMECH. — (We)agree to ave,indemnify an d keep harmlev the City of Cupertino Date Receipt# agallot liabilities,pediments,cost,and expenses which. in any wa'!L x AIRRANDLINGUMT(TO10,000CFM) SUBTOTAL: agaI tsald yfr'a sequence of the anon tape 't. nom_ AIR HANDLING UNIT(OVER 10,0DO CPM) CONSTRUCTION TAX Sigmtu Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant score or handle havrdous HEATING Uh77(70100,000 BTU) Date RBCeI t# material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code Section 2S532(a)7 [iFA71NG UNIT(OVER 100,OW B'IU) TOTAL: .� ❑Ya �No Will the appliantorfuture building occupant use equipment or devims VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE which emit haaardous air contaminants as defined by the Bay Area Air PAID C • Quality ManagementDistrid? BOILER-COMPOHPOR100,U(D BTU] PAID PYes ❑F�'�No h read the hazarRi mad,lals requirements under Chapn,6.95 of BOILER-COMP(OVER 1MD00 BTU) _ the Californla ITeaBA&Safety Code,SevtleodZ5B5,25533 and 25534.1 SEP 1990 undcmtandthatifthebuildingdwsnmt rrently,haveatenanLthatllismy NEWRESIDFNIIALMECH. SQ.FT. responsibility to notify the occupant of the requirements which most be met prior to issuance of a Certificate of Ocmpa nry. City of{f rone-hon i Owner or authorized agent Date ISSUED BY: N ( t TOTAL OFFICE COPY