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21022 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PFRM[TNO. Building Address: _ 21022 1`158 L /'rusk Latae_ cope-din wners arae: f one: A - I L. sS CITY OF CUPERTINO-BUILDING DIVISION � cgnnradora Name: Lie. g: APPLICATION / PERMIT BUILDING-ELECTRICAUPLUMB(NG-MECHANICAL CATEGORY - CONTROL p Architect/Engineer. Lk.No: n QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: 19 7 LI 'uA.�aye., a4✓�� LICENSED CONTRACTOR'S DECLARATION PERMITISSUANCE [I] 0'..' I hereby affirm that am licensed under provisions of Chapter 9(comeneru APPLFANCESRESIDENTIAL JOB DESCRE'ITON ingwlth Sedlan7000)of Division 3 ofthe Business andProfemionsCode,and my license Is in full fattened effect. PANELS License Clam Lk.0r Date nt Coradar - ARCHITECTS DECLARATION 701-1000 AMPS q�q�uu 90 O I understand my platy shag be used as public records. OVER 10010 AMPS Eh.FF.FLOOR AREA S/SQ.Fr. E Licensed Professional SIGNS ELECTRICAL R < OWNER-BUILDER DECLARATION - SPECIAL CIRCUIT/hil 7e, IherebyafflmntFatlam exempt(romthe Contractor's License Law(or the oo qq following remora.(Section 70315,Business and Prefesslune Code:Any city or ty countywhich requiresa permittomwtrvct,alter,improve,dennlish,orrepalr TpMP.METER OR I'O 5 HORN '� 3 anystmu mprlwtoltslmuame,aborequimtheappli=tforouchperMtla 15 O�� file a signed statement that he is licensed pursuant to the provialom of the EWER DEVam ICES Q6 Contractor's License Law(Chapter 9(conm ening with Section 7000)of Divi. SWIMMING POOL ELECTRIC AL TION.O 3sion 3 of the Business and PrefessloexCeds)orthat he is exempt therefrom and CJ G the basis for the alleged exemption. Any violation of Section 70315 by any no S'-7 D a applicant for a permit subjects the applicant to a civil penalty of nmore than OUTLETSSW[TCE�SFIXTURES ofive undreddalhm(5500). NEW RESIDENTIAL ELECTR SQ.FC. SrO1tI TYPE CONSTRUCTION QQQQ I,as owner of the property,or my employees with wages as their sole nsation,will do the work and the structure 6 not Intended or offered for O .Is(Sec.7044,Business and Professions Cade;The Contractors License Law e$g does nee apply to an owner of property who builds or improves thereon,and OCC.GROIIP RES.UNITS who does such work himself or through his own employees,provided that such Improvements are not Intended oroffered for sale.If,however,the building or TOTAL: - Improvementt.wldwlthlnoneyearofcompldtb theowner-bullderwiBhave - til,kurden of proving that he did net build or Improve for purpose ofsale3• QTY. PLUMBING PERMIT FEE FLOOD ZONE APN Lj L as owner of the property,am exclusively contracting with licensed ppRMIT ISSUANCE contrectom to construct the project(See.7044,Business and Professions Code: The Contradoes License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) builds or Improves thereon,and who contracts far such ptojedn with a FEE SUMMARY cgR[pdor(s)licensed pursuant to the Contractor's License Law. . BACK FLOW PROTECT.DEVICE Ll l am exempt under Sec. B&P C for this reasonOUTSIDE FEES Owner - _ - p. i. Dare DRAINS FLOOR ROOF,AREA,COND. SANITARY RECEIPTR WORKM COMP SATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y N ❑1 hereby affirm that I have a certificate of consent to self-Insureora RECEB'L M 35110,Lab C3 - certificate of Workers'CompensationInsurance or a certified copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N Policy p RECEPT pGAS EA.SYSTEM-OVER 4(EA) Cany BUILDING DIVISION FEES omOCertRodcopy V hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE Certified copy Is filed with the cityInspection division. ' CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT �Date Remi tic (Thls section need not be completed If the permit is for one hundred dollars (5100)orlmea WATER HEATER W/VENT/ELECTR ENERGY FEE' Y_ N_ I certifythat In the performance of thework forwhich this permit Is issued, - I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING , Workers Compensation Laws of Calffornia.Date PAID O Z Applicant NIEWRESIDENTIALPLMB. SQFT. Date Recei t# Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should Lemma sub)ed to the Workers'Compensation provisionsof the Labor TOTAL: ~ N Code,you=at forthwith comply with such provisions orchis permit shall be D W > deemed revoked. - BUILDING CONSTRUCTION LENDING AGENCY SEISMIC FEE D c.f(h worm'that there is a construction lending agency forthe perform- TOTAL: ELECTRIC FEE L) Z Lendee Name It for which this permit is issued(Sec.3097,Civ.Q OO f<naera Name � PLUMBING FEE - F Lenders Address QTY. MECHANICAL PERMITFEE MECHANICAL FEE O W 1cartifythatl have read this application and statethatnheabove information - - C Ia mingt building commictioh all ndhereand by authom representatives des olawe PERMIT ISSUANCE FEE >. ,[gin } W cityrelatoenteru pont ronsuuRloryanedl property for represenpurposof this `f7J�/L cityW)aree to give,indemnify an propharroess to Cit purposes. ALTER OR ADD TOMECH. e ? (We)agree m rove, encs,cdty an d keep harmless the in a of Cupertino Date ReOTAL V against liabilities,judgments, oft expenses which may in enywayaccrue AIR HANDLING UNIT([010,000 CFM) SUBTOTAL: agar teald CityIn cg aquas oft granting of this permit. - �it-�A.�la � � _ /a_�. AIR HANDLING UNIT(OVERIO,000CFM) CONSTRUCTION TAX Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:, HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous. HEATING UNIT(TO 100,000 BTU) Date Recei Hf material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTI) TOTAL: ❑ You NO Will the applicant ofuture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) - ISSUANCE DATE which emit hazardous air contaminants as defined by the Bay Area Air PAID Quality Management0striR7 BOILER-COMP01IrOR100,000BTM ❑Yee No I have read the hazy ous materials requirements under Chapter 6.95 of BOILER-COMP(OVER100,0DO BTU) SEP 13 11](10 the California Health&Safety Code,Sections 25505,25533 and 75534.I JGr s7 r7 understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Fr. responsibility to notify the occupant of the requirements which most be met C prior to issuance of a Certificate of Occupancy• int offCupell'no Owner or authorized agent Date TOTAL: ISSUED BY: l ` � ✓�, OFFICE COPY.