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21484 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY Building Project Identification PERMITNO. Bu hog Address: '214 8 4 /I ,i , {aA1C� h�fl N�Q r I f/U one: APPLICA11ONSUBMIIIA1=A - CITY OF CUPERTTNO-BUILDING DIVISION �n _ CW In C(�ot(r/a�aora N ma: Llc. o: APPLICATION / PERMIT r Cf o - catij r4 BULDINGELECTRICALPLUMBINCNfMHANICAL CA RY CON1tOLN ArchICM ner. LlcNo: 01-Y ELECTRICPERMIT FEE BUILDING PERMIT INFO Address PERMITISSUANCE ❑ ❑ ❑ ICF,NSED CONTRACTOR'S DECLARATION Hanchyafflrm that l am licensed under provisions of Chapter 9(commene- APPLIANCESRESIDENHAL JOB DESCRIPTION Ingwlth Section 70OO)of Dlvlslon3ofthe Bushdsand ProfessionsCode,and m Ilnnse le In(uB lggqqssqqpN and erreR. � ^^ PANELS I. -7Clas+ !S Cont ice! Date-/�(5-�'�s�ContndorUP TO 200 AMS ARCHITECTS DECLARATION 201-1000 AMPS PQ+O`LOCC I understand my plarashall be used as publicrecoWs. OVER IODO AMPS SQ.17.FLOOR AREA $/SQ.ET. E U Llmrowd Professional AGNS ELDCTRICAL �< OWNER-BUILDER DECLARATION SPECIALCRCUIT/MLSC 71.., Therebyaffronthat lamexempt fromtAe Contractors License Lawforthe O following reamn.(Section7011S,Businewand Pre(essiono Code:Any city or t. TEMP METER ORPOLE INST. K4 countywhire requlrna permit usuancomvdruM alter,requirsthemprovgdemsuch,ermit to a any structureprier tent thauanco,licca sed pursuant to forsuchto POWER DEVICES V (Ilea actor'd statement that he le Ilwmed pursuant to the len 7000)a( the 3µ Con3ofthee LicBusiness and rofesser9(mmnnncing eI.exith emptth 7000)of Divi-1 O G SWIMMING POOL ELECTRIC (he 3os he the alleged Professions Any alrthathebeection here(mmary }IQLUATION d <5 the blab for the alleged eecta the n. Any violation o(Sectlon 70315 by any OUTLETSSWITCHESEXIUR fiveapphundrera d delta.IBM. the applicant tea dull penitydnd mom Rico a flue I,a.. .r.fthapr. NEW RESIDENTIAL ELECTR �n ❑Lasion,wof theproperty,or my empbyedwith ended as offered STOWFS TYPE CONS'IR[X:T'ION' C compensation,(St. 044 Badnessl do work and the si.. ode:Th n Intendedontractor or callers.Ter 5 dale(Sec. pply Rusbiessandf property Code The or Impdofa Licene Law J 5$ does nonsuch torn owner of trough his onemplrimprwnded th t,and OCC.CROUP RE£UNITS F. who dodsuchwork hinneaorthreugh hisownemployees,providM thaiduch Improvements are not Intended muttered(orsale.If,however,thebuilding orTOTAL: improvement bdold within eneyearofcompletion,the owner-buUderwill have ttaIjurden of proving that he did not build or Improve for purpose of sale.). QTY, PJ- NG PERMIT FEE FLOOD ZONE APN L j L as owner of the property,am exclusively mntrading with Monne. contractors to construct the project(Sm 7044,Business and Profaoloas Code: PERMIT ISSU The Contractor'.License Law does net apply to an owner of property who �.�-D -WA (EA) Wilds or Improvn thereon,and who contracts for such plot.with a FEE SUMMARY egpl(actarW licensed pursuant to the Contractor's License Law. IX TEC . C I am exempt under Sec. B&P C for,this reason D N R COND, SANITARY Y_ N_ Owner Date RECEI N WORKVIANCOMPENSATIONDECLARATION PER QI hereby Affirm that 1 have a certl0cate of consent to del-Inert,w a SCHOOL TAX Y RECEIPT N certl0catoofWorkers'CompenalionlmunnreoramrtlfW ropyhereof(See, GAS .SY 1 NC,4 I7ILET5 PARK FEE Y N 3800,lab C.) RECEVF M I A I'eI1cyM AS.F.A. VER4(FA) BUILDING DIVISION FEES Com anv_�N{I,y bp1- Certified ropybllere !uM GREASE/ WASTE INTERCEPTOR PLANCHECK FEE Certified ropy b(Ikd with the sly Idpedbn dlWelon, CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE IRb PAID COMPENSATION INSURANCE SEWER-SANITARY STORM EA H)OFT Date Recel-t# (I'hbeectlen need not becompleted If the permit b(wane hundred dollars U100)orfyth WATER HEATER W/VENT/171 TR ENERGY FEE Y N I cenot that In the pr'dormnin an theworkmanter(o as to b this permit b Issued, I.hall not employ any Laws f any rttanner m u to become object le the WATER SYSTEM/TREATING Workers'Compensation law.o(Callfamla.Date PAID 0 Z Applicant NEW RESIDENTIAL PLMB, SQET, Date Recei t# Z O NOTICETOMPLICANT:IL aNer,making this Certificate of Ezcroption,yen should become subject to the Workers'Cemperetatlen pmvbied.(the Labor TOTAL: N Code,you must forthwith comply with such provisions or this permit shall be BUILDING FEE W 9 deemed revoked. CL c CONSTRUCTION LENDING AGENCY SEISMIC ELECTRIC F I hereby a(Brm'rhat which t i a corutroction lending agency for the perform- ELECTRIC FEE L) Z Lenderthe work forwhkh this permit Is Issued(Sec.3097,CIv.CJ TOTAL: LLO Lender's Iy H L nder'.Name PLUMBING FEE Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE OW beret.Itdgmencreadhbappllcitynand dcuntyordihuboveinformation ddatelaws 1 Is correct. buildig comply withaction all ndhereb rouhorim represeandeesoftws I'ERMITISSUANCE FEES PAID - >. W relating oenterupon t e bone, en;enedpropftyfrl in representatives of this city Wenleree to the indemnify an property less th Cit ofCu es.Cupertino ALTER OR ADD TO MIGH. Z (We)deme to eve,Indemnify en d keep harmless the City of Cupertino - ale Receipt# V against liabilities,judgments.coesand..Pa..which may in anywayacave AIR HANDLING UNIT(TO 10,ODO CFM) SUBTOTAL: agaWtaa Cityin cone enceof the granting of this permit. iii Q AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX Slgrffiwreo( cot/Conlnctor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or fumm building occupant store or handle harzrdous HEATING UNIT(TO 100,000 BTU) Date RCCCI t# material as deft ned by the Cupertino Municipal Code,Chapter 9.12,and he Ilealth and SafetyCodlre_-_S,Iection 25532(a)1 HEATING UNIT(OVER 100,000 BTU) ❑ L: ill he applicant orfutum building occupant use equipment or devices VENTILATION FAN(SINCLF-RESID) ISSUANCE DATE which emit haaardousaircontamlruntsas defined bythe Bay Area Air Quality ��� ay.lJ D (� Management District? BOILER-COMPC1HPOR 100,0(*BTI!) { Yes ❑No have read the harurdousmaterias requiremenh underChapter6.95 of BOILER-COMP(OVIR 100,000 BN) ' the CAIllornia health&Safety Code,Sections 25505,25533 and 255M. I N;jda ass fa..daeyyjn® undenWnd that if the building does not currently have a tenant,that It b my NEW RESIDENTIAL MECH. SQ.FT. SFI1 V'L LUResdut! responsibility to notify the occupant of the requbr'menta which moat be and prior to Issuance of a Certificate of Occupancy, O vaer or authodred agent DateISSUED UY:]s •lY`V W'1QANa/aVs TOTAL: OFFICE COPY