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21932 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY Building Project identification PERMIT NO. Building Address: q1 3 _F.2�� 21932 .YIA `,9g D✓�' hog` ' CITY OF CUPERTINO-BUILDING DIVISION -. A�jA/ Co ctor'tN me: �. �:© APPLICATION /PERMIT 3 l \S r <l BUILDING-ELECTRICALPLUMBING-MECHANICALCATEGORY CONTROL# Architect/Engineer. Lir No: �y ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: 357 ! OLLA, LLE�-i PLUMB MECH ,`�/#+ PERMITISSUANCE N ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9(comment APPLIANCES-RESIDENTIAL JOB DESCRIPTION ing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in fu o d effect. PANELS ���� V,6D u Licen lass Lic# S�� Date I Contractor ARCHITECTS DECLARATION 201-1000 AMPS O I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT. �r d 0 Licensed Professional SIGNS ELECTRICAL �. L E D tom-Q i~ OWNER-BUILDER DECLARATION v t.., I hereby affirm SPECIAL CIRCUIT/MISC that I am exempt from the Contractor s License Law for the ZO following reason.(Section 7031.5,Business and Professions Code:Any city or H TEMP.METER OR POLE INST. ��// � PUTE county which requires a permit to construct,alter,improve,demolish,or repair any structure prior to its issuance,also requires the applicant for such permit to POWER DEVICES DA E U file a signed statement that he is licensed pursuant to the provisions of the t 3 w N Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION O sion 3 of the Business and Professions Code)or that he is exempt therefrom and Q the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS-SWITCHES-FIXTURES O _ applicant for a permit subjects the applicant to a civil penalty of not more than o O five hundred dollars($SM. SQ•.7•• STORIESTYPE CONSTRUCTION cn " NEW RESIDENTIAL ELECTR ❑I,as owner of the property,or my employees with wages as their sole compensation,will do the work and the structure is not intended or offered for psale(Sec 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who doessuchwork himself orthrough hisown employees,provided that such OCC.GROUP RES.UNITS improvements are not intended oroffered for sale.If,however,the building or TOTAL: improvement is sold within one yearof completion,the owner-builderwill have the burden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD TONE APN ❑L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE to construct the project(Sec.7044,Business and Professions Code: The Contractors License Law does not apply to an owner of property who AI TEg DRAIN&VENT-WATER(ITA) builds or improves thereon,and who contracts for such pkojects with a FEE SUMMARY contractor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE El am exempt under Sec. B&P C for this reason OUTSIDE FEES Owner Date DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y—RECEIPT# N WORKMAN COMPENSATION DECLARATION �.�5 PER TRAP SCHOOL TAX Y_ N ❑I hereby affirm that I have a certificate of consent to self-insure,ora RECEIPT a certificate of Workers'Compensation Insurance or a certified copy thereof(Sec. 3800,Lab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y— N_ Policy# RECEIPT# Com any GAEA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES ❑pCertS ified copy is hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE ❑Certified copy is filed with the city inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars SEWER-SANITARY-STORM EA.200FT. Date Recei t# ($100)or less.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N I certify that in the performance of the work for which this permit is issued, I shall not em loy any person in any manner so as beco ps1yJ?je�to the WATER SYSTEM/TREATING PAID Workers'Co �c�ti9n sof forny►.D `f� Z Applicant 1 46/. E/ NEW RESIDENTIAL PLMB. SQ FT. Date Recei t# O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should become subject to the Workers'Compensation provisions of the Labor TOTAL: _Ln Code,you must forthwith comply with such provisions orthis permit shall be BUILDING FEE '0 U > deemed revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE L I hereby affirm that there is a construction lending agency for the perform- ELECTRIC FEE D Z ance of the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: 0 Lender's Name PLUMBING FEE H Lenders Address cry. MECHANICAL PERMIT FEE L UJ is 1certifythatIhave readthisapplicationandstate thattheabove information MECHANICAL FEE is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID: Nrelating to building construction,and hereby authorize representatives of this city to enter upon the above me Toned p for inspection purposes. ALTER OR ADD TO MECH. Z (We) a to save,Inde fy an harmless the City of Cupertino Date Receipt# again ilities,judg sts a which may in anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: .S- Q agar i in c e g of this permit. AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX gna of reAp can ontractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HA RDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t# material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: ❑Yes M No Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSphbATE which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District? BOILER-COMP(3HP OR 100,000 BTU) Yes y 1 i (�" have read the hazardous Nomaterials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) �.f h { E S J 1 the California Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FI'. responsibility to notify the occupant of the requirements which must be met city of prior to issuance of a Certificate of Occupancy. �J r Owner or authorized agent Date TOTAL: ISSUED BY: U OFFICE COPY