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21510 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building project Identification PERMIT NO. BuildingAddrta,: 21510 ;a _� nen D r one: �!raS r� vJ?6 ffl-1 S1_/'f -) 3 CITY OF CUPERTINO-BUILDING DIVISION can[ndare Namr Lie,No: APPLICATION /PERMIT L `�0` BUILDING-ELECTRICAL PLUMBING-ME NiCAL CATEGORY CONTROL 4 Arc ce, glnear, Lie.No. QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: PERFITISSUANCE r��1 ❑ ❑ ❑ LICENSED CON ACTOB'SDECLARATION - Iherebya(firmthe l sin licensed under provblonaof Chapter 9(mmmenc APPLIANCESRESIDENDKI, JOB DESCRIPTION ing Mth SeR1on7000)of DiAsion3 ofthe Buslnessand ProfesslonsCode,and 11®nee la In full form and died. - PANELS License Chas Llctl Date Contractor Lip To 2paAmpq114 +� ` • �" ARCHITECTS DECLARATION 2014000AMPS pqqF!!oZ Iunderstand my plain shall be used as public records. OVERIOWAMPS SQ.Fr.FLOOR AREA T/SQ,FT. E 05 Licensed professional SIGNS ELECTRICAL <6 OWNER-BUILDER DECLARATION SPECIALCIRCUT/MISC 7s, Iherebya((Irm that!rim ezemp[fmrmlhe Contractor's License Law for the ' C following reason.(Seaton 70315,Business and Profession,Code:Any city or TEMP.METER ORIOLE INST. - En countywhidh requlreaa permlttocormtmct,alter,lmpanve,demoWh,orrepalr S anystmMm prior to Bs issuance,aborequirestheappllcant fmsudh permit toPOWER DEVICES _ �0 fS file a signed statement that he b licensed pursuant to the provisions of the P63µ Contractors License (Chapter' LiLaw (mmmendng with Section 7000)of Dist. VALUATION I'n SWIMMING[BOOL ELECITUC efon3ofthe Bne usissand lho(e®IaroCodb e)orthat heezempt[herefromand G ] the bosh for the alleged exemption. Any violation of Section 70D5 h1'any xis OUTLETSSWITCHMFIXTURFS IIs$Q appUcant for a peemh mbjedsthe applkantto a dull pemlty d not more than Eve 1.a,o nerdela.of he ON. NEW RESIDENTIAL ELECTR SQ.FT. S TIBTES TYPE CONSTRUCTION I,ss owner ll of property,or he employees with wages rte thele sole C compensation,0K wBldotherd work TlmfdiomCde: is notIntenorcensoffered Law 5�0 site(Sec 7004,Business and Professloru Code:TheContractor's License Law $ does net apply to an owner of property who builds or Improves thereon,and OCC.GROUa RFS.UMTS whodoessuch work himself or through his own employees,provided that each Improvements are not intended or offered for sale.If,however,the building or Improvement b sold within one yearofcompldlon,the owner-bullderwill have I, Ryk ttiLJ2urden of proving that he did not build or improve for purpose of este.). QTY. PL B[ PER [ FEE FLOOD ZONE APN LJ L as owner of the property,am exclusively=trading with I— P©14IT rontnaors to mwa ec rmthe panted(S 7066,Business and Pro(esslorm Cade: The Contractor's License Law don net apply to an owner of property who AL .DRAT -WA builds or Improve,thanon, and who mntram for such ptojecta with a FEE SUMMARY cgR{Iaam(s)UmnsM ec pursuant to the Contraaor'a License Law. BACBACKOTFLT. CE LII am exempt under SB&P C for this reason DRAINS. P.ROOF, CON jj OUTSIDE FEES SANITARY Y_ N_ Owner Date RECEBPT If WORKMAN COMPENSATION DECLARATION FIX.URE TRAP SCHOOL TAX Y N ❑I hereby,fit.that I have a certificate of consent to self-Insure,or a RECEIPT« certificate o(Workers'CompnuaHan Insurance ma certified copythereoHsac. GAS -tl O ETS PARK Fl7: Y N Policy M Lab CJ RECEIPT'X Policy S1TM-0V (EA) RI, � BUILDING DIVISION FEES Certified copy is hereby fuml,hed. GR E IND TE INTERCEPTOR PLANCHECKFEE Certlfled copy b filed with the city Inspection division. CERTIFICATE OF ET(EMPTION FROM WORKERS' G T PAID COMPENSATION INSURANCE SANITAR EA.2001T Date RCCCI t# (fMsseakn need net be completed if the pemdt b forom hundred dollars 3100)mloa) WATER HEATER W/ /ELECTR ENERGYFEE Y_ N_ I certify that In the performance of thework(orwhlch this permit Is Issued, I shall not employ any person in any manner so as to become subject to the WATIR SYSTEM/TREATING Workem'COmpeosatlon Lawsol CallfOmh.Date PAID QZ Applicant NEWRESIDENTIALPB. SQ%T. - Date Reeel tN Z LMO NOTICE TO APPLICANT: making this Certificate of Exemption, Fshould become subject to the WmrkenCompewatbn provbinroaf the Labor TOTAL: N Code,you twat forthwith comply with such provisions orthh permit shall be BUILDING FEE W E3 deemed revoked.CONSTRUCTION LENDING AGENCY SEISMIC FEE tl I hemby a(Orm that there b a emestmdlon lending agency forthe perform- ELECTRIC FEE 7 Z ance ofthe workfor which this permit Is bound(Sm.3097,C1v.C.) TOTAL: (� O Lander,Name PLUMBING FEE LL r Lenderseadrea, QTY. MECHANICAL PERMIT ITE MECHANICAL FEE OW I certify thall have readthisapplic tionand statethat theabove Information 1 lacormot.Iugmeto comply with all city and county orlinareasand state laws PERMIT ISSUANCE FEES PAID: } W relatingtobulldingmmlrualoryand herebyauthorize reprearr Utiveso(thl, F Z city toenterupon the above-mentlormd property fee Inspection purposes. ALTER OR ADDTO MECH. Date ReCeIPt41 (We)agree to save,IndemN(y an d keep harmless the City of Cupertino AIR HANDLING[JM78010,000 CFM) L) against liabilities,pdgments,cousand a:pensee which may In anyway acme SUBTOTAL: agaUml said City in consequence oft granting of this permit. � � � �a,yx9n AIRHANDLING UNIT(OVER IO,000CFM) CONSTRUCTION TAX sigruludre of np�picam/Eontracto Date EXHAUS"f HOOD(W/DUCT) CONSTRUCTION TAX PAID: .HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle harsrdous HEATING UNIT(TO 100,ODO BTU) Date Recei tp material n defined by the Cupertino Municipal Code,Chapter 9.12,and the Health andSafety Code Session 25532(,)7 HEATING UNIT(OVER 10,000 BTU) TOTAL: I]Yea No Wllltheappltantm(uture building occupant use equipment or devices VRN77LATION FAN(SINGLE RESID) IS$Jf> DATE which emit hazardous air contamirmnts as defirmd by the Bay Area Air CA1 W silty Management Dhtrict7 BOILER-COMP DFP OR 100,000 BTU) Y. ®No O have read the harirdous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BIV) PEG Q 1�arR the California Health&Safety Code,Sed1ore 8505,25533 and 25534. I H understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQFL responsibility to notify the occupant of the requirements which most he rtM dy�.-t hrwer�� pdortolssuarm ofa Certlfkate !Occupancy. r'1 Yi cupeaY Owner or authorised agent Date ISSUEDB VC TOTAL: OFFICE COPY