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21409 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY Building Project Identification PERMIT NO. Build Ing Add ress: 21409 d c.c. neve ams: y2 one: p A . �� � p L(J� /✓S 7y0� CITY OF CUPERTIN0.6UILDING DIVISION Gan ado:eN.me: Lic.No: APPLICATION I PERMIT ('�L •- B 3 BUILDING-ELFCTRICAUPLUMBING-MECHAMCAL CATEGORY" CONTROL N Architect/Engineer. Lie.No: evr/ QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO rad remSq fA7'gCIJ—SuNNY✓�7/E.CP, Si yr. PERMITISSUANCE © ❑ ❑ LICENSED CONTRACTOR'S DECLARATION I hereby af(Irtn that l am licensed under provisions of Chapter 9(commanAPPLIANCHSRESLDENEDAL JOB DESCRIPTION Ingwlthse ..7000)ofDWkim3oftheBudn andPmfesslmsCode,and my &-7744E7 2sf+aTv�'2 license is In(u d cited. PANELS Limn Class LIc.N �p Dale — Contradar lit L31 /ye//1/G 201-1000 TO 200 AMPS ARCHITECTS DECLARATION � CO I understand my plane shag be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT. NUB Licensed Professional SICNSELECTRICAL �6 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC z4Iherebyaf/lrm that l amexemm pt frothe Contractor's License Law for the o following remm.(5ectlon 7031.5,Businea and Profession.Code:My city or FZF'u� countywhlch requires a permit tomratruct,alter,improve,deanikh,or repair TEMP'METER OR POLE INST. any structure prior to its Ease.ace,also requires the applicant for such permit to U file a signed rtatement that he In licensed pursuant to the provab ns of the POWER DEVICES w Contractor's License Law(Chapter9(commencing with Section 7000)of Diet. � O I'n SWIMMING POOL ELECTRIC elon3 otthe Bualnemand Pro(esslom Code)orthat helaexempttherefromand VALUATION < the bask(er the alleged exemption. Any violation of Stolon 70115 by.ey OUTLETS-SWITCHES Z00 oO applicant fora permit subjects the applicant toa civil penalty effect more than I fiy� 00). hundred della.BIS M. J NEW RESIDENTIAL ELECTR �n Last waid.the property,or employees wlthwagm ore thered for —�'FT• 'STORIES TYPE CONSTRUCTION compensation,Bust the workandthestrodurekrad Intended or offeredfor ,J O cote(Sora 7644,Buelmus end Professions Code:The Contractors License Law does ndapply Loan owner of property,who Wilds or improves thereon,and �pCC.CROl1P RES.UNITS 0.0. whodoeaeuchwcrkhlmselforth=gh hieawnemplayree,provided thatsimh c/y / improvements are not Intended orolfered for sale.If,however,the buildingor TOTAL Improvemsntksoid within omyearofcomplebrytheowner-buRderwillhave the burden of proving that he did rad Wlid or Improve for purpose ofsakJ. QTY. PLUMBING PERMIT FEE FLOOD LANE APN u I,as owner of the property,am exclusively contracting with Ilcenmd PERMIT ISSUANCE /!� aTa oO cont.cto.to construct the project(See 7044,Business and Professions Code: The Contractor's Llanee Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) Wilds or Improves thereon,and who contracts for such paajeck with a r�actor(s)licensed Pursuant to the Cont.dors License Law. BACK FLAW PROTECT.DEVICE FEE SUMMARY LJ I am exempt under Sec B k P C for this reason DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N • Owner Date RECFII'T N K WORMAN COMPENSATION DECLARATION O FIXTURES PER.TRAP .� SCHOOL FAX Y N 101 hereby&!(Iran that I have•certificate of consent to aelf-Insure,or• RECOPT N certificate of WarkeWComperuatlon Insurance ora certified copythermUSee. 3800,Ieb C.) GAS EA.SYSTEM•]INC.40UTLEIS PARK FEE Y N PoltryN GAS EA.SYSTI1d-OOVER RINCDIN C,,,o���m,,,pppany BUILDING DI VISION FEES I]O Certified copy la herebyformatted.the cid. GREASE/INDUSTRI.WASTE INTERCEPTOR PIANCHECK FEE Certified copy k filed with the city Inspection division. CERTIFICATE OF EXEM PTION FROM WORKERS' CREASE TRAP PAID COMPENSATION INSURANCE (Thissectloneard ndbemmpleedlftheperMtkforomhundrcddolla. SEWER-SANITARY-STORM EA.200FT. Dale Reccf t# (S10Woify that WATER HEATER W/VENT/ELECTR ENERGY FEE Y N l artilythat Nthe persona In e of any the work to which a tobthiopermitkko the — I shall not employ any person In any aria. a m to become subject to the WATER SYSTEM/TREAT(NG Workers Compensation Laws o(OII(omla.Date PAID O Z Applicant NEW RFSIDEN7IAL PCMB. Date Remi t# Z O NOTICE TO APPLICANT:If,ager making this Certificate of Exemption,you —50'FT' should become subject to the Workers''Compematlon provisions o(the Labor TOTAL: W Code,you must forthwith comply with such provisions orthk perMtahall be 9 damed revoked. W G CONSTRUCTION LENDING AGENCY SEISMIC FEE 0 d Z I hereby affirm that there Lt.cornu uctlon lending agency for the perfomm 7 M ELECTRIC FEE ansa of the work for which this permit k issued(Set.3097,Civ.C.) TOTAL: 2 Vs+ 02 Lenders N. PLUMBING FEE LL t- Lender'°Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE O WIwAifythatlhavemadth;applimtionandgatethattheabaveinfomutlm L kcorred.I agreeto comply with all city and countyordinancevand mate lawn PERMIT ISSUANCE FEES PAID: } N relating to building mretrudion,and hereby authorlm representatives ofthk )— Z city to enter upon the above-mentioned property for impection purpose°. ALTEROR ADD TO MECH. Daft Rxei t# — Me)agree to save,Indemnify an d keep harmlm the City of Cupertino P against liabilities,judgment,mstsand expenses which may In anywayacerue AIR I EANDLING UNIT(TO 10,000 CPM) SUBTOTAL: a agalm/tt Ed City in con emx fthe granting ofthis permit. �� 3 Z7y1 AIR HANDLING UNIT(OVER I0,01DOC11M) CONSTRUCTION TAX SIfEuMm ofAppllcant/Contractor Date EXHAUSTHOOD(W/DUCT? CONSTRUCTION TAX PAID: HAZA BOGUS MATERIALS DISCLOSURE Will the a pplicarat or future building occu pant more or hand Is hazardous HEATING UNIT(TO 100,"BTU) Date material..defined by theCupartino Mu nicipal Code,Chapter 9.1 2,and the Reeel t# Health and Safety Code Section 25.532(a)I HEATING UNIT(OVER 100,000 BTI) TOTAL: Q nYes No Wllltheapplicamerr rum building occupant use equipment or devious VENTILATION FAN(SINGLE BRED) ISSUANCE DATE which emit bazardous air cents minand as defined by the Bay Area Air • Quality Mansgemant Dist d7 BO)LER-COMP DEEP QRIOO,DtD BTU) ,�(p� [?have l Yes No r'�IIC haveread earthhe ase f&y Code,Soceoraa25enkundernd 2554.1 of BOILER-COMP(OVER 1110,000 BTU) M theerstand that ifthhe bSalciy Code,Seccomntlyhve-(cnd25534.I "IPI understand that lcilly the ing occupant not erequire encs which that It met NEW RESIDEMIAL MECH. SQ.FT (7 responsibility to ndlfy the occupant of the requirements which mus be met ' prior Issuance ofa Cert III otOmpancy. ,_M 3-27- 9/ &s0C� Owner or authorised agent Date TOTAL; ISSUHD BI� OFFICE COPY