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19752 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Proed Identification PERMITNO. Building Address: 19752J11M8 oN1E5i£Ap RA• SO11f A Phone: A A )M%v ALLEI &TE 6V0, CITY OF CUPERTINO-BUILDING DIVISION G,°^"` ° •Na LIC.N°: APPLICATION I PERMIT W 1 LLDG• cuiNtR ALD 41'loao BUILDING-ELECTRICAI.PLUMBINGhfECHANICAL CATEGORY TCONTR Archlts /�nginyy��'r. Lie.No: 1 173 LKS M3kocr BUILDING PERMIT INFO QTY ELECTRIC PERMIT FEE Address PERMITISSUANCE El 1:1 ❑ LICENSED CONTRACTOR'S DECLARATION I hereby affirm that lary licensed under provisions of Chapter9(commune. APPLIANCESRESIDENTIAL JOB DESCRIPTION Ingwith Se ion70DO)of Divlsion3ofthe Bupneeand Profespom Code,and my license Is in full force and d1w. PANELS 77 LicenseClass Lic.N '�— Date Contractor — UP TO 200 ANTS ARCHITECTS DECLARATION 201-1000 AMPS re02 I understand my playa shall M used a public records. OVER 1000 AMPS SQ.Fr.FLOOR AREA S/SQ.FT. O Licensed Professional SIGNS ELECTRICAL that lam exempt ERDECLARATION SPECIALCIRCUIT/MISC ,t.., owingrason. tMton 7031mptfromthed Peofitorb License Law canoe / pO following reason.(Section7031S,to Business and]improve, Code:Any city it O L i-� TEMP.METER OR POLE INST. countywhich mor to spemntttocomtrut,alter,lmprovgdemolkh,orto Fm�� any a signed prior to Issuance,lice rcqu pursuant rovisior mompermit e POWER DEVICES fie a signed statement that M b licensed pursuant t°the provislow of the a�� CommSeN ratoesLicenseLaw(Chapter9(ceromencingwlthon700()ofavi- SWIMMING IDOL ELECTRIC O cion 3 ofthe Businessand PfessionsCode)orthat he b exempt themmmand VALUATION �^ the Mals for the alleged exemption. Any violation of Section 7aML5 by any <5 applicant for permit sub' the locant to a civil penalty arm more than 011'II,ETSSW[TCHFSFIXTURCS fvP el lis PP P H O/ OOO a:R five hundred dolbrs(5500). NEW RESIDENTIAL ELECTRSQ.FT. 7 ❑1,as owner of the property,or my employees with wages as their sok SIORIfS TYPECONSIRIKHON rompensation,w ldotMworkandthestruturehnm Intendedor offaedfor sale(Sec.7044,Business and ProfessionsCode:TM Contratoe.Lice.law j$ docs not apply to an owner of property who builds or Improves thereon,and who does such work himself orthrough his own employees,provided that such OCCGROUPRFS.UNITS Improvements are not Intended or offered for sale.If,however,the build Ing or TOTAL: improvement issold withinoneyearofcompiattomthe ownerbullderwlli have tlIii*rdenof proving that he did not build or improve for purpose of aale.). QTy, PLUMBING PERMIT FEE FLOOD ZONE APN u I,as owner of the property,am exclusively contracting with homes i PERMIT ISSUANCE contactors to construct the project(Sec,7014,Business and Professions Code: The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA) Wilds or improve thereon,and who contracts for m such ptlejewith a ,,IIIItt(Tador(s) icensedpumuanttothe Contractor'oLlmnw Law. =LI I am exempt under Sec. B k P C for this maaon BAIX FLOW PROTECT.DEVICE FEE SUMMARY OUTSIDE FE Owner DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N Date RECEIPT N WORKMAN COMPENSATION DECLARATION pIX.�S�.�P SCHOOLTAX Y N �I hereby affirm that I have a, r§l tc of consent to self-0neure,ora RECEIPT N certificate of Workers'Comperaattonlroyranceora ttrtlf4d copythertrof(Sec. MOD,Lab C) PL "04,1 s,O)5 CAS-EA.sysrFaMa INca ounErs FC- -I�I Y PARK FP.E Y_ N_ Policy Vny I GAS EA.SYSTEM-0VER4(EA) BOIL RECEIPT IVISION FEES ertllled copy's hereby(urniah GREASE/INDUSIRL WASTE INTERCEPTOR PLANCf-IECIC FEE C ertified copy Ls filed with ted city Inspection division. CERTIFICATE OF O(EMPTION FROM WORKERS' GREASE TRAP' PAIDa as-CO � COMPENSATIONleaft eS rR ti fo SEWERSANITARYSTORMEA 200pr. Date RCmI f#g3JS (Thos or In..) need eat Mcompleted lithepermsbfor orae hundred dollars (8100 unify WATFRHEATERW/VENT/ELECTR ENERGY FEE Y�, N Illnot thato the persoainanthework for which this permitctissued, _ 1 shall not employ any person In any manner m e to Wcorn¢subject to the Wmken'CompensattmL-ws Of California. Date WATER SYSTEM/TREATING PAID223qD S`ml? �'T�A z Z Applicant makins)s0-Z Z O NOTICE TO APPLICANT:If,after g this CertBRevel t# Vlcateof Exemption,you NEW RESIDENTIAL PLMB. SQ.Fr. Date should become subject to the Workem-Compemation provisions of the Labor TOTAL: you=at forthwith comply with such provisions orchis pert shall be W > dee-Codemmi ed revoked. BUILDING FE IL O CONSTRUCTION LENDING AGENCY SEISMIC FEE - 2. 00 I hereby affirm that there u m a construction lending agency for the perform, 7 Z anis of the work for which this permit b issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE U O Lenders Name PLUMBING FEE 1L Lenders Addreas QTY. MECHANICAL PERMIT FEE O EILIO Ianifythat l have read this application and statethatthe above Information MECHANICAL FEE a boomed.Iagreeto complywith all cityand county ordinances and pate laws PERMITISSUANCE PEES PAID: W relating to building construction,and hereby authorize representatives ofthis F Z city to enter upon the above-mentioned property for inspection purposea. ALTERORADDTOMECH. (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt# against liabilities,Pdgmenb,cosi expense which may lnanyway.mnm AIR HANDLING UNIT(TO 10,ODO CFM) against said City In conuquenco of the gra rating of this permit. SUBTOTAL. M R HA NDLING UNIT(OVER I BoDO CEM) CONSTRUCTION TAX Signatumod Appiiam/Contractor Date EXHAUST HOOD(W/DLKD CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or land le hazardous HEATING UNIT(TO 100,070 BTU) materia l as defined by the Cupertino Mu nicopah Code,Chapter 9.1 2,and the Date Reeei t# I❑alt Yesd Safety CodNoon 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: �•O Will the appllant or ture Wilding occupant useequlpment ordevices VENTILATION FAN(SINGLE RESID) which emit hamrdous air contaminsets as defined by the Bay Area Air ISSUASSUAtNCE DATE f4, Quality Management District?; BOILER-COMP©HPOR 100,000 BTL; 4Y r/No have rcadthe hav mmaterials requlrerentsundcrChapter 6.95 of BOILER-COMP(OVER 100,00)BTU) /bf`� the California Health k Safety Code,Sections 25505,25533 and 25534. I 1 Ll understand that if the building does not ttrrewly have a meant,that It is my NEWRESIDENTIALMECH. 9Q.FT responsibility to notify the occupant of the requirements which must be rest Rf (sIIct GF)Ir10 prior to Issuance of a Camflate ofoccvpancy. Dom..— 2 12 z/y, Owneror�ithorized agent pate TOTAL: ISSUED s OFFICE COPY 1