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21745 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification TI �Y -� PERMIT NO. B°"ding AEdR", l� 21745 1 � `� 4 Q tort C_a.ct.,,L.C�1QIc— Cin r Lr1 era �. one A A A f-610af CITY OF CUPERTINO-BUILDING DIVISION Tract. Na : . r� Lic.N . APPLICATION / PERMIT C' BUILDING-ELECTRICALPLUMBING-MECIEAMCAL - CATEGORY CONTROL M • chltm gine .v ' ;� C Qn ELECTRIC PERMIT FEE BUILDING PERMITINFO Address: PERFBTISSUANCE LICENSED CONTRACTOR'S DECLARATION - IhembyaFEX ffirm that[am licensed under provisions of Chapter9(mmmenc- APPLIANCESRESIDE.NDAL TOB DESC ON Ingwith Senbn7000)0/DlNslon3ofthellusiressard Profes'socesCode,and my L Anse Clarlicense s in R r L!N L�- 36 9 T PANELS Date Contractor l'V ARCHInCPS DECLARATION 201-1000AMTS iYY� �7 l understand mype usea Public mror lamshallbd blida OVER 1000 AMPS SQ.FT.FLOOR AREA f/SQ-17. O Licensed Professional SIGNS ELECTRICAL OWNER-BUILDER DECLARATION SI'EC7ALCBiCUIT/MISTS P, IherebyafRrmlhat l am exempt from the Contractor's License lawforthe Z D following ream.Section 7MI5,Business and Professions Code:Any city or QOC .✓ O L I-u9 TEMP.METER OR POLE INST. rmu ./ 5 ntywhlch requlreaa permit tomnstruct,ilter,lmprove,demolbh,or repair 11 � anystmaartprbrto lTSBsuance,cels°mqulmtheappBontlm such permit t° POWER DEVICES C s.5 file a signed statement that he Is licensed pursuant to the provisions of the - w Contract./,License law(chapter 9(commencing with Section Mid Divi- VALUATION Ot' sion3ofthe Business and ProfessionsCole)orthat he h exem therefromand SWIMMING IDOL ELECTRIC Qa the Want for the allegedpermit %o exemption. Any t toa ioncivil d natty Of not ex b3'any OUTLETSSWITCI-DSEXRTRES /�� / C applicant hundred redfor aper dollars, j. the applicant Toa dVil pevlty Of not rromtlun P. O� fivchandmdddhmhepr. R_ NEW RESIDENTIAL ELEC STORIES TYPE CONSTRUCTION I,as owner o/the property,or he employees in with wage as thele role k7a compensation,will do Businessawork.andtheCde:TheCs not ldende,License for Law S�❑ sslc l.Eec.7004 Business and Professions Cade:The Contractors License Taw ( $$ does not apply loan owner of property who builds or improves thereat,and \ MOCGGROUP RES UNITS C whodoessuchwork himselforthrough hisownemployees,provided thi teach OUTS I OF FEES improvements are not Intended oroffered forsale.If,howeveq thebullding or T Impmvementissoldwithinoneycarofcompletlogtheowner-bullderwlll M1ave �aL.Tq t)r�rden of proving that he did not build or improve for pu rp.ssof ask.). QTY. PLUn WFM ADD LONE APN u I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7014,Business and Prcdesilons Code: I'FRIMI ANCE The Contractor's License Taw don no apply to an owner d property who ALTER-DRAIN 4 VEM-WATER(FA) wilds.r improves thmon, and who contracts fee such pyo"with a FEE SUMMARY mp(laderW licensed pursuant to the Contractor's License Law. BACK FIAWPROTE�T.DEVICE LII am exempt under Sec B 6 P C for this mason DRAINS.flAOR ROOF,AREA,GOND. SANITARY Y_ N_ ® Owner Date RECEB'f e WOBm=t COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N_ cert ❑1 hereby affirm that 7 have a ceaturan a of consent to op the rre,(S a RECEIPT s 3800,Lto ab C.mpensatlon lrnunncexaartl(kd copy thereof(Sec. CAS EA.SYSTEM-1 INCA OUTLETS PARR FEE Y N 330Q Tab CJ Il.liq N REC[PTX C,, GAS E .SYSTEM-OVER aBUILDING DIV ISIONFES ertlfed copy b hereby famished. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE Certified copy b filed With the city Inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM FA.200FT. Date Recci t# Sb Rhbsectlon need nal b completed If the permit V[crone hundred dollars (5'°°)ncefn ) WATER HEATER W/YpM/ELECT.R ENERGYFEE Y N Irtify that uthe performance of the wmkfor which this permit bbsued, I ahs 11 not employ any person In any manner m as to become subject to the WATER SYSTEM/TREATING Worker:Compensation Laws of California. Date PAID - 0 Z Applicant NEW RESIDENTIAL PIMB. SQPY. Date Retmi t# _Z 0 NVTICETOA]suLICt to If, after rrs'Comaking Cois mpensation krovisate of Exemption,of the Lyou TOTAL: shouldbecomesurtoto the comply such pruatbn provisionstithe Lab or ~ N Code,youokM.Mhwhh comply wltM1 such proWions or this permit shall be ILI — BUILDING FTE W > deemed rtvokN. CONSTRUCTION LENDING AGENCY SEISMIC FEE CL Ihcrcbya/frm that them Ls a corutrualon lending agency for the perform ELECTRIC FEE Z ancoof the Work for which this permit Is laved Sec.3097,Cls.Q TOTAL: Q0 I<nder.Name b PLUMBING FEE LL F tendce,Aaam„ QTY. MECHANICAL PERMIT ITE MECHANICAL FEE O W Imrtlfythatl have m.dthl.ppli tWnanastatethat The abovelnformatio^ ucorrect.I alimeto comply withal)etyand county ordinances and state laws PERMTTISSUANCE FEES PAI �'��C1p/ } N relatingtobdldingornslructlon,and hereby author.e representatives./this 2 60_t a Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADDTO MECH. - V _ (We)agree to save,Irdemd(y an d keep harmless the City d Cupertino ate Receipt# against Ilablllties,judgments,macs and expenses which mayinanywayaxxae AIRFIANDUNGUNTT(TOI0,00(] M) SUBTOTAL' against said city In.pnsaryence o!the granting of this permit.C AR AND NG UMT OVER IO,OWCFM) CONSTRUCTION TAX Signatumof Appllont/C actor /D— � EXILAnusTIlODD6v/DUCT) CO SN TRUC ON TAX ID: UA2AR OULSDIS LOSURE / b Will the applicant or future building o¢vpants reorhandlehavrdou, HEATING UNIT CIO 100,ODO BTU) Date Recei t# material as defined by the Cupertino Municipal Code,Chapter 9.12,and the - Fkvlth and SafetyCode Sedion 25532(a)7 HEATING UNIT(OVER 1W,"BTU) TOTAL: M Yes M No fltz Wlllthea llce.t or futumbuildin occv luxe ui ment ordevices VENTILATION FAN RESID) PP 8 P+^ h P ISSIbANLSaF]ATE which emit hamedow air contamivnb as de0ned by the Bay Arta Air Quality Management District? BOB.ER-COMP pFE'OR 100,IXD ITV) ❑Yrs ❑"° EB 1 1991 (h ave read the Farar us No requimrrcnta under Chapter 6.95 of BOILER-COMP(OVERIW,OW BN) F 4 1 the Glifer^ia Health A Safety Coda Sections 25505,25533 and 25534. 1 , undcrstard that ifthe bullding docs not cvmently have atenanL tM1at it is my NEW RESIDENTIAL MECH. SQ.FT responsibility to not l/y the xcupa^t d the requirements which rust be met mile�y� 0 SSrIn' s prior T°Lsauance da CcrtifiateyfwOmrpan Ownerar au rlud agent 'Date LSSUEDBY\�l� v TOTAL: OFFICE COPY