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21584 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PERMIT NO. Build Add 21584 came: one: APPLICATION SUBMITTAL 15= Al'./ 41 _ CITY OF CUPERTINO-BUILDING DIVISION °r• fame, �j�Llc.No: APPLICATION I PERMIT '4 BUILDING-ELECTRICAL PLUMBINGMFLHANICALCATEGORY CONTROL M R gineer: Lt.No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Add. PERMTISSUANCE ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION 1Mrcby affirm that l son Ike...d under provisions of Chapter 9(mmmeno APPLIANCES-RESIDENTIAL JOB DESCRIPTION Ing with Section 7000)of Division 3 ofthe Business and Profession,Code,and my - n/ N1-6714 � t It.. ,m kLre__ C�«a° � a� �� PANELS Aeea 7�'�.yL-6714 C —UP TO 200ANVS ARCHITECPS DECLARATION 701-IOW AMPS /` _e rx u017O I understand my plane shall be used as public records. OVERIODOAMPS SQ.FT.FLOOR AREA S/SQ.FT. ��rC7l L Licensed Professional SIGNSELECTRICAL _ O/�, L E D ' << OWNER-BUILDER DECLARATION G V P T E `!n SI'ECIALCB2CNT/MLSC VV Zt,�S Iherebya(Orm thatlam exempt fromthe Contractor's License law for the following reason.lSedlon 70115,Bushes and Pm(e®bv Code:Any dty or O Ocounty TEMP.METCR OR POLE INST. x P arystm are nqulmess issuance, costmuires kheaprovgdemolbh,orto L/ any aWmare priorto statement ahat he is alsored pursuant to the rovidomormich ofpermit e �WEg DEVICGS rN1 � 0le a signed Naterrent that he h licensed ponoses(to the provhlos of the w Contractor.License Law(Chapler9(mn ed.gwlth Section 70)0)of Dlvl-SVALUATION OS eloeloftheeuslnex,ond Profx kmCode)orthat hehexempttherchomami SWIMMING 1170E ELECTRIC Sn 5 the basis for the alleged exemption. My violation of Section 7011.5 by any OUTLETSSWITCHFSHXIURES applicant for a permit subjects the applicant to a civil penalty of nor mom than five hundred dollars MW. �n ❑I,asowner ofthe roe NEW RESIDENTIAL ELECTR__SQ.FT, STORIES TYPECONSTRUCTION property,py,or my employees with wage(as 1MIr Bole Oown pensation,wllldothe work and lhestructum Is not Intended or offered for sale(Sec.7064,Business and Professions Code:The Contractors Llano law 5$ does not apply to an owner of property who build,or improves thereon,and who d°essuch work himself or through his own employen,provided that such OCC.GROUP RFS.UNITS improvements am not Intended or.ffrmd fmaide.If,howevep lhebuilding or TOTAL: improvement bsold within oneyear°fcompletiogthe owner-bullderwi l have tgLlIurdenof proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN u L as owner of the property,am exclusively contracting with licensed PERMITISSUANCE contractor,to construct the project(Sec.7054,Business and Pro(esioru Code: Elm Commctor.License Law does not apply to an owner of property who ALTER-DRAIN&VEM-WATER(EA) builds or Improves there°n,and who mntmeas for such p(ojeds with a �gIJ 01T+doKk 8)licensed pursuant to the COntradors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY I am exempt under See. B P C for this reasonOUTS I DE FEES Owner. Date DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N BBC=B 1slA.rcby ORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL FAX Y N �I71rcby affirm that I have a cenlBnte of consent to selGlnvre or RECEIPT N anifiose dw.ukers'COmpesafitm Insurance Or.artlfled copy therm(Oec. CAS EA.SYSIFAt-1 llJC.40l1TLETS 3800,Lab C.) ? PANK FEE Y N Poliryp /�A'�iA/O L RECEIPTa GAS FA.SYSTEM-OVER 4(EA) Com anAl Fp—� 6/O - BUILDING DI VIRION FRES [�Ce If(ed ropy h filed the city CREASE/INDUSTRL WASTE INTERCEPTOR PLANC14ECK FEE �enti(led copy h filed with lM city Ispectlon division. CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID COMPENSATION INSURANCE SEWER-SANTrARY-STORM EA 2WFT Date Remi t# ITM1ieeectlonneed matMENSATI NIiftheperreftINSURANCE dollars (SIW)orless.) WATER HEATER W/VENT/dECTR ENERGYFEE Y N I mnifylhat In the performance of the work forwhich this permit Is Issued, — I shall not employ any person In any manner m as to become subject to the WATER SYSTEM/TREATING Wmkmm Compenapinn Lawsof Cahf.ia. Date PAID 0 Z Applicant NEw RmorxnAL PLMB. RQ.FT. Date Recei t# Z p NOTICE TO APPLICANT:ILaRer making this Certifialeof Exemption,you should become subject to the WorkersCompensation pmvhiosofthe Labor TOTAL: _ W Code,you at forthwith comply with such provisions orthh permitahall be 1 �s W D deemed mvoked. UI d ssu CONSTRUCTION LENDING AGENCY SEISMIC FEE 1 I hereby affirm that there h a mstmudlon lending agency for the perforin ELECTRIC FEE Z anceof the work for which this permit ts lei&c.WO,Civ.C.) TOTAL: U O lender.Name PLUMBING FEE LL ~ lender.Addmn QTY. MECHANICAL PERMIT FEE MECHANICAL FEE WI cenllythat I havereadthis appllationand Nate thatthe above Information 1 Iscorrect.l agree to comply with all city and county ordinances and Nate laws PERMIT ISSUANCE FEES PAID: >. W relating to building construction,and hereby authorize representatives ofthis - F Z city to enter upon the above�mentiosd property fee Inspection purpose,. ALTFRORADDTOMECH. Date Recei t# — (We)agree to save,Indemnify an d keep barreled,the City of Cu penn° Pi against liabilities,ju dgments,cops and expenses which may in any way accrue AIR HANDLING UNIT(TO 10030 CFM) SUBTOTAL: against said City in consequence of the granting of this permit AIR HANDLING UNIT(OVER I O,ODO CFM) CONSTRUCTION TAX Signstam of Applicant/Contractor Date 2)(HAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 1W,000 BTU) material as defined by the Cupertino Municipal Code,Chapter 9.17,and the Date RmeI t# I lcalthand Safety Code SO 32(a)7 HEATING UNIT(OVER IW,OW BTU) TOTAL. ❑Yn o Will lheeppllcantorfutum building pact use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE which emit hazardous air contaminants as defined by the Bay Area Air Ouality Management D'is o BOILER-COMP 0HPOR 100,000 BTU) B •dread the haze Due materials requirements under Chapter 6.95 of BOILER-COMP(OVER IW,WO BN) in% lforniallealth&Safety Code,Sedios25505,25533and2SSM.1 0-Ad that lilhebuildln MIs not mrrcnllyhav ant,that it is my NEW RESIDENTIAL MECH. SQbT. Y(In' �s ��iIlty ton Ifytheo pant oft re Iemoa must be mel NP Nj 2priuance ,Cert o CI(Y1 Ow rorauth°dzed agent ISSUEDR OTAL: — OFFICE COPY