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19887 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL'POINT'PEN ONLY BuildingPr°ed Identification - - PFRMTT NO. .Q Q ' ] BnuangAaare : N i1�11 D 7 �, C� �e JUU 1 wearsName: - �t7 CITY OF CUPERTINO-BUILDING DIVISION. G °" a ° "'R t1 LI LI "°. APPCATION 1 PERMIT " �� it E^Ri tt2� BUILD INGELECTRICAI.PLUMBINGMMHIA A.L CATECORY CONTROL v` PERMITINFO- BUILDING, Q'h'; 'ELECTRIC PERMIT "FEE - Add.; �J(d . .�}`{�I� /. PERMITISSUANCE '. r LICENSED CONTRACPOR'S DECLARATION a _ (hereby affirmthat I am licensed under provisions of Chapter 9(commen' APPLIANCES-RESID NTIAL '- IJOB DESCRIPTION Ingwith Sealon7000)ofDlvlsion3ooftbir Busbieesa"d ProfessimtsCode,and my Jj censelC nae 11 f andLlceN / PAN©9 Date ontracto ARCHITECTS ION 201-IODOAMPS• q�v 41X I understand my plana shall he used as pu c records. OVER 1000 AMPS 5{j.Ff.FLOOR AR`F�{..� - ;/SQ.FI. •Ft� Licensed Professional SICNSELECTRICAL �(,/ . G'<1 OWNER-BOLDER DECLARATION SPECLILCIXCUIT/MIST' / io., l hereby affirmthat I am exemptfrom the Commetur's License Law forthe ZO Z Q following reason.(Section 70315,Business and Professions Code:Any city or - ruiq' ,coutntywhich requirma permarocmntruct,alter,improve,derclbh,orrepalr TEMP.METER ORPOLE INST. W8v anystmcture prlorrolb issuance,elw requlresthe appgcant(or eucM1 pertNt t° POWER DEVICES •1 'f t`�w�8 file a signed statement that he b hod sed pursuant to the provisions of the , Q6 3 p t Co dm-rb License Law(Chapter 9(mmmmcing with Sectio"7000)of D1vl- SWIMMING]VIOL ELECTRIC ei.n3.fth.BuaineasmdProfmv mCude)orthatheisexamptthemfmmand VALUATION f9 c S the bosh for the alleged exemption. Any violation of Section 7011.5 by any GP --3�5l OFto _ applicant for a permit subjects the applicant to a civil penalty of not room than OUTLETS—SWITCHES-FIXTURES "��-.11! < GGG111n five hundred dollars($511), OPP. �n L as owner of the property, NEW RESIDENTIAL ELECTR SQ.FT. ❑ p peaty,or nd he s employees with wages as Their sole STORIES TYPE CONSTRUCTION compensation,0K Business andwill do the keeadma, octure Is Code:The ot Conttendedo icenseafor _ Q O sale(Sec. pply to alnowandf property Code:The orimptlots hereon Law '$ docs not apply roan owner ofproperty whoWilds nemporlmprovethereoMand who I.P.o ssuchworkhimxBorthroacgh offemd owale.If yees,provided ,theb thatsuch O�a G . yard,; improvement issold ithmoneyearofcompl sa n,the owevep deer il:haw 'TOTAL: K Improvement ateold withinoneyearafcamplgiaryted owner-bu0derw1li have - t119-llurdenofprovingthathedWnabuildorImproveforpurposeof sale.). QTY. PLUMBING PERMIT : FEEi I Ll L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE- �� roG contractors to construct the project(Sec 7044,Business and Professions Code: jagagas The Cont etor'e Lice..Law does net apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) ' builds or Impve thereon,and who contracts for such projects with e ador(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE " FEE SUMMARY I am exempt under Sec 0 &P C-for this mason DRAINS FLOOR ROOF,AREA,CONTI. .. SANITARY Y N ..Owner Date RECEIPT'N WORK MAN COMPENSATION DECLARATION FIXTURES PER TRAP ' SCHOOLTAX . Y - N ❑I hereby affirm that I have o In uia c of consent to self-Ir recof ora RECEB'T N cegi0rab o(Workers'Compewatlon Insurance oracertlfkd copythereo((Bec. CAS EA.SYSTEM-1 INCA OUTLETS, PARK FEE' Y N 3XOQ Lab C.)' Policyd - - - RECEIPT X. Cam any - GAS EA.SYSThT1.OVER4(EA) BUILDING DIVISION FEES 1 ECertified copy b hereby th the ed.dry GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE ' E3 Certified copyis filed with the city Inspection division. .� 't CERTIFICATE OF EXEMPTION FROM WORKERS" • GREASE TRAP .r 6 s//• /9O /y� COMPENSATION INSURANCE - }PAID Uhlasetlbnneed not be completed ifthe permit is forone hundred dollars SEWER-SANITARY-STORM EA.20017. Date Recei t# (;t 0o)arfess.) WATER HEATER W/VENT/ELECTR - - ENERGYFEE Y IN I shall Amy that emin ploy an person any numner so as to b co permit is booed, — I shag not employ any person In any manner se as to become mbjeci to the WATER BYSIEM/111RAT.ING _ Cj'/�A p Workere'Compeneation Lawn of California.Date - PAID J O Z Applicant NEW RESIDENTIAL PLMB. SQjrL Date Rec'ei t# Z O NOTICE TO APPLICANT:$after maWompe Ceronlcate of Exemption,you Hshould become subject to the Workers'Compeneatlon pro vision ofthe Labor , �. TOTAL:. LUN Code,you must forthwith comply with such provisions°rthb pe' tahallbe j• deemed revoked. ILDINC I ,6 CL G CONSTRUCTION LENDING AGENCY. SEISMIC FEE I herebyafRrrothat there b a mrutruction lending agency for the perform TOTAL: ' ELECTRIC FEE 6 3 Z anm°f the work for which that permit b I)Issued(Sec.3097,Civ,C.) : - - V O Lenders Name PLUMBING FEE D 'LL H Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE (7j O W Icertifythatl have read thbappIleatWnana stMethattheabove information 1 ismrrect.I agreeto complywlth all city and county ordinances and gate laws PERMIT ISSUANCE �. (2) FEES PAID: N relating to building commotion,and hereby authorize representatives of this - - - a - - f Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. - V — aiRAZACRDO demnify an9ERIALSV91SCSURE ty of Cupertino Date Receipt# erro,rog anywayaccrue '. - AIR HANDLING UNIT(T010,000 CPM) •SUBTOTAL: eque of thO AIR HANDLING UNIT(OVER 10,000CFM) " 'CONSTRUCTION TAX '2C actorDate ' EXHAUSI'HOOD(W/DUCT) CONSTRUCTION TAX PAID: battRDO E - WllltheapplicantorfuturebuBdingoccvpmEst° .,lutrlleh.rdoua HEATING UNIT(TO 100,000 BTU) Date R2Ce1 t# material as defined by the Cupertino Municipal Code,Chapter 9.12,and the; - He-'altY sd Safety C°de,See[Ioon 25532(x)7 HEATING UMT(OVER IW,OW BTIn •1 TOTAL:: Ill the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESIDE ISSUANCE DATE ' which emit hamrdous air contaminants as defined by the Bay Area Air Quality Management DattrN - BOILER-COMP(3FII'OR 100,000 BTU) - 4Ye 1�No havereadthehaza'3ouso aterialsrequimmntsunderChap(er6.95of BOILER-C'OMP(OVER 100,000 BTU) /)r)t_ the California Health&Safety Code,Sections 25505,75533 and 25534.1 a..:�^asy understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. r responsibility to notify the occupant of the requirements which must be mLt - prior to issuance of a Certificate of Om Is ocy. /aj/u� 1�.e•. s aVF' r, Owner or authorlud agent Date ' - ISSUGDBY:V—� �t TOTAL: a. OFFICE COPY `