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21280 (2) APPLICANT TO FILL IN INFORMATI N WIT INR LINES — USE BALL POINT PEN ONLY -Building roject IdentificationPERMIT NO. Building Address: I� aMQ.) P� -�-�" wo1 21280 wners sine: —���,�� ons: p a �.ozos .'c t.((�.� I TCW I Z CITY OF CUPERTINO-BUILDING DIVISION c tattoraName: ^J ` LIC-No: APPLICATION / PERMIT BUILDINGFl TRICALPLUMBING-MECHAMCAL CATEGORY CONTROLN Archlted/Englneer. Lic.No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: I O5441,6.,01 . PERMITISSUANCE ® E:] 1:1 ❑ LICENSED CONTRACTOR'S DECLARATION I hereby,affirm that l am licensed under provisions of Chapter9(mmrvnc APPLIANCES-RESIDENTIAL JOB DESCRI'DON Ingwith Sect1on7000)of Divlslon3ofthe Buslarseand Profeaalom Code,and my License is in full f6o A� Lk.effect -m s /p/ PANELS License Clans 1o.� Cleft JPO OD47 a��v f ✓G�\ Date_frfj_ s_CHITIiar �/ ( _/� s plansUP TO 200 AMPS HITECT4 DE public mounds. s. OVER 20mWOAMI'S rc0 Z❑O I understand my plan shall be used v public remrds ,�,OVER 10(p AMPS,I �.FT.FLOOR AREA 5/SQ.FC. Fi o`j Licensed Professional SIGNSELECrRICAL << <ro OWNEReBUILDER DECLARATION fn fd /� SPECIAL Cl2CUIT/MLSC p, y Thereby afOrm lhatlam exemptlromlhe Contrector'e License iawfpr ttia, I 7 9 p following reason.(Senian 70315,Business d professions Code:Any city or gyp,MLTIX ORPOLE INST. O/.H countywhlch requlresa permitmronsrm Rsr,Impmve d(anoltsii,arrcpair 4r'��1�'� anyawcture prior to lis Lssaance,alaore lheapp0r�ant Gorsuch permitto POWER DEVICES , t g a file a signed statement that M 6 Ecen muant to the proWiov of the +0�Ors Contractor's Llcamelaw(Cha erg av nYl" Ith Ssttlan 70(0)of DIA- / mU VALUATION sion3.ft cBusinesaana Profen vCode) rthat he b exempt therefromand rSWLMhING POOL ELECIRTC — h Ey O 5 the basis for the alleged axe pilon. Any Iolallon of Section 7031.5 by any OUTLE s SWITCHPSFI t IlRFS 1 �© appEcent fora permit subjects theapp0can'to atlWl penalty of nat mo a them 1 $ five bun dre owns Ilan%sm. �� �\t VO NEWR IDENITAL ELEC SQ.FI. EJL as r of the property,or my empl yeeswi{h wages as thelrlsole - SfORIGS TYPE CONSTRUCTION �7a compensation,will dolhe work and thestructure In epi nterledor offeiidfor O- S 0 sale(Sec.7004,Bust sand Pmfndmes Code:,The CoriraRorovnts Lice ' Law n $$ donot apply to an owner of property who bulkidor lmpthe n;andi OCC.CROUI' RES.UNITS who doessuchwork hlmselforthrough hisown employees,provided atsaich improvements are not Intended oroffered forsale.If,however;theb Ildi+ TOTAL: impmvemcnllssoldwlthinoneyrarofcompletiomtheo"ner-bu0d wlllha th,4urdenofpmvingthathedldroWOdorimpmv5forpu' of.1c). QTY. PLUMBING PERMIT FEE FLOOD MNE APN u L as owner of the property,am exclusively m�rtradrg w licensed PERMITLSSUANCE contractors to conaeuct the project(Sec.7044,Business and Profe IonsCode: The Contractor's License Law don not apply to an owner of p petty who ALTER-DRAIN k VENT-WATER(EA)Wilda or Improve thereon,then, and who contracts for such plojeRa with a oat dor(a)Ilanxd pursuant to the Contractor's Llcenx Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY I am exempt under Sec. B 4a P C for thin masonQUTSIDEFCUS DRAINS-FLOOR ROOF,AREA,COND. SANITARY Y_ N_ • Owner Data RPLEPI'p K h M.WORKMAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCHOOL TAX Y_ N Ei _ sal nemby athat I have a mrtllcaw te of consent to self-Inre,ora RpGEVp N certificate ofWorkera Compensation lvuratim cra certifird copythemof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARR FEE Y N 3800,Lab C.) RECEIPT p I'ollcyp_�_ �� � GAS FA.SYSTEM.OVER4(G) Ca��mo�CaSSnMMv 5 BUILDING DIVISION FEE 'la' ed copy is hereby fumlahed. �— GREASE/INDUSTRL WASTE INTERCEPTOR PLANCI'IECIC FEE citified copy Is filed with the city inspection division CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID COMPENSATION INSURANCE SEWER-SANTFARY-STORM EA 20017Date RCOCI I# (This section need not be completed if the permit is for one hundred dollars ($100)orlen.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N— I art0y that in the perfomvnca of the work for which this permit Is Issued, 1 shall not employ any person in any manner as as to become subject to the WATERSYSIFIA/TREATING Workera Compensation laws of California.Data PAID OZ Applicant NEW RES DEN AL PCMB. SQF. Date Remi t# Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should became.object to the Workers'Compensation provisions of the Labor TOTAL: N Cade,you most forthwith comply with such provisions orthis permit shall be BUILDING 00 LU j deemed revoked. W _ CONSTRUCTION ENDING AGENCY SEISMIC FEE CL M Z Ihsrthyao0rmnrhauherebacovtroctlonic(d.3genq for the perform TOTAL: ELECTRIC FEE 7 Z Lcodee he work(orwhichthb permitvlasued(See 3097,Cm.C3 PLUMBING FEE (L O Icnders Name LL ~ LcnaersAaarew QTY. MECHANICAL PERMIT FEE MECHANICAL FEE OW laft.Idi lhavere PlywitpplicatyndcuntyorUnancesedAsiaInformation aws 1 Vcorrect.l.greeto complywilh all cityand county ordinances and state lawn PERMRISSUANCE FEES PAID: } N relating to building covtmctlon,and here autho2 representatives olth0 f.. W city to enter upon the above-mrentioned perty o ectlon purposes. ALTER OR ADOTO MECH. _ Date Receipt# (W e)agree to Indemnify a d keep ha a City y Cupertino V against llabllitl grrenta, rad ex may In anyway accrue AIR HANDLING IJMT(I'010,000 CFM) SUBTOTAL: against said in consequ Wthe tinges Is Femur. O/ I / //sD AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX Sigvtinem Applicant/Contracts Data I D(HAus r HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE WdItheapp0cant orlown,building occupant store or handle hrzardous HEATING UNIT(TO 100,000BM Date Reeei t# materwI defined by the Cupertino Municipal Code,Chapter 9.1 2,and the - Ilealt rad Safety Code,Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: Yes ❑No Will the applicant or form,Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISJLjr)/ jJDATE which emit hannious air contaminants as defined by the Bay Area Air ICa�1 • Qua lity Ma nagement District? BOILER-COMP QHP OR 100,000 BTU) Yea M No 19U have mad the Manomaterials rc rtwteriaqulrcnt rrcs under Chapter 6.95 of BOILER-COMP(OVER100,000 BTU) OCT 9 2 the California Health h SafetyCode,Sections 25505,25533 and 25534. 1 understand that if the building does no ren ave nant thilt B k my NEW RESIDENTIAL MECIi. SQ_FT responsibility to no f he occvpa t f e m reins which must be met /sllaa priorm camsece CertlOcat. cevpa y. ML4'V�4�r O.vncr or authormd agent Day TOTAL: ISSUED BY: ' OFFICE COPY