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21880 (6) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification 7 PERMIT NO. Building Address: --2-1 Oct 21 O O O o[ 3 0& � d LF �D, G Q o one: p p vera ante: — GtCC-E CITY OF CUPERTINO-BUILDING DIVISION Contractor's Narrc: l`v q�' Lk.No: APPLICATION /PERMIT SLULDINGELECTRICAL.I'LUMBINGMEG LAICAL CATEGORY CONTI)e A (] Architect/Engineer. Lk.No: �9 `, 1 QTY ELECTRIC PERMIT ^FEE BUILDING PERMIT INFO Address: ' PERMITISSUANCE yC� LICENSED CONTRACTOR'S DECLARATION I hereby affirm that)amiotgonaM under pcovmoreafeedoesr9(comment APPLIANCESRESIDENfIAL JOB DESC rIION Ingwlth5edlon 7000)01 DIWsi0n3oDhegusinestand Pm(esionsC^de,and my license la In fu fo�5+ d d(en. ',,, �. PANELS Diems �. 'Contractor / e l�'a Dale Fa—CHITE4 1�!LJ NM1C�"' 2011000 AMPS _ ARCHITECPS DECLARATION a0 OVER1000AMPS SQ.Fr.FLOOR AREA $/SQ.Fr. NIqq understand my plans shall be used as public records.O Licensed Professional SIGNSELECTRICAL 531 ¢' OWNER-BUILDER DECLARATION /.C) SPECIALCIRCUI I t., y Ihercbya(firmlhat l am exempt from the Contractor's License Law forthe O lolbwing recon.(Seelo^7Qf1.5,Businem and Pmfesslons Code:Any dtym gip,METER POI. I IL Cz countywhlch requlmea pernot tocmutruct,alter,improve,demoltsh,or repair an yawdum prl^rto Its Issuance,also requlrcathe applicant for such permit to )pyyER DEVIC pE�0 V file a signed statement that he Is licensed pursuant to the provisions of the Q3s` Contractor'sLlceree Law(Chapter9(commencing with Section 7000)of Dtvl- q�SWVALUATION O¢r^ slon3oHhe Business and Profesbns Code)orthat heatexemptthercfromanSWIMMINGPOOLEL the basis for the alleged exemption. Any violation of Section 70315 by any m appH..t fora Permit subjects the applicant to a civil penalty of not orethsn IUTLEISSWITCHESFIXTUR sC)d F, $zk five hundred dollars(5500). NEW RESIDENTIAL ELECTR SQFT. STORIES7 .. ❑I,as owner of the property,or my employees with wages as their sok TYPE CONSIRIICTION compensation,will do the work and the structure b not Intended or offered for �- s 5 if(So,7034,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RFS.UNITS whodeassuchwork hlcueVorthmugh hisownemployees,provided thatsuch Improvements are not Intended muttered for sale.If,however,theWilding or TOTAL: 3-Jx improvement bsold within oneyearofcompidlon,the owner-bunderwnl have th;.p�men of proving that he dm em bund or improve fee purpose ofeak.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN LJ C e as owner of the property,am exclusively contracting with licensed contractors to mnsbuct the project(Sec.7046,Business and Professions Code: ( I'QiMR75SUANCE I aD The Contrectorb Untrue law does not apply to an owner of property who Wilds or improves thereon,and who contracts fm such pWeds with a 0 AIM-DRAIN&VENT-WATER BIM yy(Tadot(s)licensed pursuant uant t^the Contractors License Law. BA PROTFLT.DEVICE FEE SUMMARY Lf I am exempt under See. B& P C for that reasnn411 DRAINS FIGO ODF,AREA,COND. SANITARY Y N- Owner Date RECERrI'p WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOLTAX Y_ N_ ❑ affirm that hereby affirthat 1 have a mrti0rate of consent to self-Insure,w a t RECEIVE If certificate ofWorkeri Compereatlon Insurance ora cenlfle copythereof(Sec. 3 GAS EA.SYSTEM-1 WCAO ETS s� PARK FEE N Y 3800,Lsb C.) - RP.CIFIE0 Policy® GAS EA.SYSTEM-OVER 4( I Com any BUILDING DIVISION FOES nifled copy is hereby furnished. GREASE/INDUSTRL WA I R PLANCHECK FEE ❑CerlRled copy b filed with the city Inspection division. CERTIFICATE OF EXEMPT ION FROM WORKERS' IGREASETRAP 11 PAID'�a'O�\ COMPENSATION INSURANCE SEWER-SANITARY RM Fr. Date (TFlssedion need not be completed If the permit b forone hundred dollars (sIBB>or lest 2 WATER HFA VENT/ TR ) 1 ENERGYFEE Y_ N_ I certify that k the performance of the week forwhich this perne t is heated, '4) 1 shall not employ any person In any manner m ns ro become subject to the WATER ATI Workers Compensation laws of California.Date PAID O Z Applicant NEW R ALP 5 2F. Date RCcei O Z O NOTICETOAPPLICANT:ILafter Rukingthta CertBWteef Faemptbn,you should become subject to the Workers'COmpenuHon pmvlsbre of the Labor TOTAL: CC n Code,you=at forthwith comply with such provatioreorthb permit aba]late BUILDING deemed revoked. W > CONSTRUCTION LENDING AGENCY SEISMIC FEE CL Ihercbyaffim that there b a construction lendingagency forthe perform TOTAL: ELECTRIC FEE (� Z ante of the work for whkh this permit b issued(Sec.3097,Civ.CJ t PLUMBING FEE _ 02 Lender's Name LL I— Lceern Addmns QTY. MECHANICAL PERMIT FEE MECHANICAL FEE S© lcedifyihatlhavcreadthbappbmtlonandwatethadheabov nfomution O W atcomd.I egret tocompdy with all city and county ordinances and state laws PERMIT ISSUANCE 2aW FEES PAID: >. C relating tobulldingmnsbudion,and herebyauthoruce represmtativesofthts Zcid wenteruP°nthe abovementlonedpropertyfe inPeetonpuryoses. ALTE40RADDTOMECH. Date Receipt# 1 (We)a ee tot�7'Bytmd ex It rises whkh ma bar I the Cin tynof Cuperta AIR HANDLING UMT(TO 10,000 CFM) SUBTOTAL' V din abllit es pe y yway aca 1 It o egisntleg, thea perm. n o AIRHANDENGUNIT(OVER10,000CFM) CONSTRUCTION TAX Sig ns re of Appumnt/Contractor Doe EXHAUST I IOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE ��t WlllI f applicant or future building occupant stmeor handle havardous HEATING UNIT(TO 1W,fU0 BTU) Z may Date RCCCI t# materl�a efined bythe Cupertino MunicipalCode,Chapter 9.12,and the I1,,Ith and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: c ❑Yes M No Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE which emit harnrdous air contaminants as defined by the Bay Area Air Qualityes Management District?No ROn.ER-COMP OIIP OR 1fp,IXtO BTU) P�/D 4havercadthebavrF7i-IousmateriabrcquirementsunderChipler6.95of BOILER-COIP(OVIRlW,000BTU) �7E the Celifornla Health&Safety Code,Sections 25505,25S33 and 25534.I understand that if the building does not corrently have a tenant,that it fix my NEW RESIDENTIAL MECH. 9Q.FT. responsibility to notify the occupant of the mqulmments which must be met prior to Issuance of a Certificate of Occupancy. `- e I 1, Owner m authoduTOTAL d agent Date ISSUED RY: OFFICE COPY