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21719 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Buildln Project Identification 1 �_ �� p, PERMIT NO. Building Addrcn: 1..� �JOan � 21719 r. a one: A A A _` CITY OF CUPERTINO-BUILDING DIVISION rtca", �: ( APPLICATION.I PERMIT BLTLDINGaDcTRICA4pLUMBINGMECHAMCAL CATEGORY CONTROL a n/ .artiness IY ELECTRIC PERMIT FEEBUILDING PERMIT INFO Address. PERMIT ISSUANCE r LICENSED CONTRACTOR'S DECLARATION I hereby affirm that l am licensed under provisions of Chapter 9(commenc MPLIANCFSRE9DE.NRAL JOB DPSCRE'WN licozseti mf.11f� fDieffect theBusine andl'pilnyonaCode,and my PANELS Er+ '/'�I License DContractor •Ly/\C /\ I &o L Date ttt�....JJJ ARCHITECI'SDECLARATION 201-1000AMPS '06,7 !understand my phra eM1aB be used a public remmla. OVER 1000 AMPS SQ.FT.FLOOR AREA . $/SQ.FF. a Licensed Pmf.t..l SIGNS ELECTRICAL � G< OWNER-BUILDER DECLARATION SIPFLIALCIRCUIT/MLSC 'ZH�t.., Ihersbya/fiern that am exempt from the Contractors License law for the following ecaon.(Section 7015,Business and Pmfesions Cade Anycityor `(7 FZF.a� countywhich rcqulrcsa permitroaomtrua[,alter,lmpmve,demolbh,orrepalr TEMP.METER OR POLE INST. anyatmc mptlortolt.lmance,alsorequirestheappliuntforsuchper tto c. file a signed statement that he b licensed pursuant to the pmWion of the POWER DEVICES Oy Contractors License Law(Chapter 9(mmmencingwith Snt1an7000)ofDivi- F,Ei sion 3 ofthe Buslnioe.ed Peadeame Code)mthat he b exempt therefromand SWIMMING POOL ELECTRIC VAI(lI;�TION ^ !�G 5 the baala for the alleged subjects Any violation of Section not re any OUTLETSSN77CHESFTXTURFS / / D/ ) HN applicant fora pemdt subj<slheapplicanttoa dull penalty momthan C/ c.- $ five hundred dollars(LOO). I,as owner of the NEW RESIDENTIAL ELECTR SQFT, STORIES TYPECONSIRLCTION i 7 compensation.will dothe w«kandrt my b we intended or offered for a F O sale(Sec.70µBusLass and Profession Code:The Contractor's Llceme law does not apply to an ower of property who builds or improves therewn and c.$ whodoaauchworkhimself orlhreugh hisownemployeea,provided that such OCC.GROUP RES.UNITS improvement art not Intended oroffemd forsale.If,howevegthebuilding or TOTAL: improvement hwld wilhmoneyearofcompletiogtheownerbu0derw111 have th rden of proving that he did not build or improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE FLDODZONE APN _I,a owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE mntraRors to mavtmet the project(Sec.70K Busines and Profession Code: The Contractors License Law does nor apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA) Wilds or improves the., and who contracts for such pnojem with a c aeror(s)IkLnsed pursuant tome Contractan'a llanx Law. BACK FLOW PROTECT.DEVICE 'FEE SUMMARY L-J I am exempt under Sec. B k P C for this reason1­11 TTSI LE hat tDRAINS FLOOR,ROOF,AREA,MND. SANITARY Y_ N_� Owner ECL RECEIPT s WORT COMPENSATION DECLARATION FD(TURES.PER TRAP SCHOOL TAX Y_ N_ ❑1 hereby affirm that I have a certificate of consent to sell-insure,ora RECEIPT sertl(lolc o/Workers Compewtionlvuraneemaeertlfled copythemo(6ec. GAS FA.SYSTEM-1 INCAOUFI.E-IS PARK FFR Y N 380,lab CJ Conry a RECEGAS EA.SYSTEM-OVER 4(EA) DING DT I CEcent H'•.-Nati (a�.\F\. BUILDING DIVISION I[T:B Certified copy is herebyfamished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE ©Certified copy t filed with theetlty WpeRlon dlvlalon. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.20F1'. Date Rewi t# (C)o cess.) need not Mcompleted lithe perMl tforonhundred dollen J LTl O)oifyth WATERHFATERW/VENT'/E-ELTR ENERGY FEE Y N lllrot thato the peresoeI.anynce rehe wmk forwhichthispemNtisto the — I shall not employ any.Laws In any manner w a to become subject m the WATER SYS I/TREATING Warken'Compeaatlon laws of Glifornla. Date PAID O Z Applicant NEW RESIDENTIAL PIMB. SOFT. Date RCeeI t# Z O NOTICE TOMPLICANT:H,after making this Certificate of Exemption,you W should become subject to the Worken'Compensrtmro n pvtn loof the Labor TOTAL: Code,you must forthwith comply with such provisions or this permit shall be . LU j deemed eevakLd. BUILDING EE W E CONSTRUCTION LENDING AGENCY SEISMIC FEE r Il Ihercbyafflrthat them h a construction lending agency for the perform, Z ancooftheworklm Is cd(Sec.3097,Clv.C.) TOTAL: ELECTRIC FEE Q0 1<adce.Name / - - PLUMBING FEE LL ~ Lender',Addicts - - QTY. MECHANICAL PERMIT FEE Is MECHANICAL FEE OW I certify that l have read this appli ion and tatethauheabovelnformalion 1 correct l agree to comply with all cityand county ordinances and state laws PERMIT ISSUANCE FEE PAD: N relating to building construction,and hereby authorize representatives of this I F Z city to enter upon the above-mentioned property for Wpectlon purposes. ALTER OR ADD TO MECH. Date RCCeI [# _ (We)agree to save,Indemnify an d keep harmles the City m Cupertino P r against liabilities,Judgments,metsand expenxswhich mayln anywayacwe AIRHANDLINGUMTpO10,000CFM) SUBTOTAL: agatat old City in mnsryuen¢ol the antingofthiaperou. "`l AIR HANDLING UNTT(OVER IQ0e0CFM) CONSTRUCTION TAX Sigiutum of Apptican ontnctor —� Date / IXFIAUSTIIOOD(LV/DOLT) CONSTRUCTION TAX PAID: HAZA R DOU5 MATERIALSDI L.OSU RE 14._1 L+i_ eta Will the applicant our fttombuilding occupant ort or handle havnlous (BEATING UM7(TO 10,000 BTU) material asdefined by the Cupertino Municipal Code,Chapter 9.1 Z and the ate RCCCIPf# t Elealth and SafetyCade Section 25532(a)? IBEATING UNIT(OVER 10,00 HIM - TOTAL' ❑Yo 1]No Will the applicant or future building occupant use equipment or devices VFNDIATION FAN(SINGLE RESID) ISSU/JJN_AWE ' which Loft havrduusair contaminants.,defined by the Bay Area Air - Quality Management District? .BOILER-COMP CIEMOR 10,00 BU)T Yea n❑Nw FEB 141991 havercadth.Ith&SafutYat ,l di.0 underChapter of BOIL[R-COMP(OVER 10,00 BN) the Gufnd la Heath4Safetycode,net currently urr ntlyh have. e.d,that. I ' understand to notify tithe he occupant of themclu onects tenant that itis my NEW RESIDENTIAL MECH. SQ.FF. rapanaiissua m.f.Cthe occupant of the rtqulrtments which most be met day' prior to Ls Oce da Certificate of Pam / Z y Pi 0,P.Hts• s Owner or autharizwagent Date TOTALISSUED BY_ : — - OFFICE COPY