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20448 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY IBuildingProject Identification PERNI1TNO. Building Address: b�020448 ere ams: ne. A A P ° CITY OF CUPERTINO-BUILDINGDIVISION �7 ` Z� c° as°''a Jame: u°.N°: APPLICATION I PERMIT �Lmer, BUILDING-ELECTMCALPLUMBING-MECHAMCAL CATEGORY CONTEIV 0 1 C/ Amhlte `Engineer. i Lk.No: f0 4 QTY ELECTRICPERMIT FEE BUILDINGPERMITINFO Address: , SV A PERMITISSUANCE r%h ❑ ❑ LICENSED CONTRACTOR'S DECLARATION - jny I hereby affirm that l am licensed under provisions of Chapter 9(mmmnnF APPLIANCMFIESIDENML JOB DESCRIPTION ingwilh Section 7000)of Division 3 ofthe Businessand ProfessfoosCode,and my License b m In full forand effect. PANELS LicenseClam Lit.# ( A Date Contractor E� UPT02DOAMM ARCHITECPSDECLARATION 201-IDOO AMPS q�q�uu ail Z I understand my plaro.hallbeused as public record.. OVER IOW AMPS EQ.FT.FLOOR AREA E/SQ.FT. Fi Licensed Professional - SIGNSELFCTRICAL <6 OWNER-BUILDER DECLARATION SPECIALCIRC M Zs, a I herebyd0rm that l am exempt from the Contractor's Lice®e Law for the following reason.(Section 70315,Business and Professions Code:Any city or �.,� TEMP.METER OR L I S � county which requires apertN[rocoraWcl,alter,impmve,demollah,arrepalr g anystmd mpriortoiu%manceb nmi ,aomquimatheapplicantf.r..chpette RDEVICES file a signed statement that he is licensed Nesuant to the provisions of the 3 u. Contractor's License law(Chapter 9(commencing with Section 7000)of IRA- Mon 3 ivi-Mon3 of the Business and Professb VALUATIONlwaCode)orthat he exempt therefrom and NG P(X)L C • Gthe basis for the alleged exemption. Any violation of Section ITS by any O SW[TC Applicant for a permit subjectsthe applicant to a civil penalty dnot more Ilan five hundred dollars($SM. NEW R D EL E4 fr.El 1,as owner of the property,or my employees with wages as their sole coSTOW TYPE CONSTRUCTION t compensation,will do the work and the structure not intended or offered for 5' 00 ale(Sec 7064 Business and Profculons Code:The Contractor's License Law does nor apply to an owner of property who builds or improves thereon,and OCC.GROUP RFS.UNITS 6 who d°eeauchworkhrreadforthrough hleownemployees,provided thatsuch improv¢menb are not Intended orolfered for sale.Il however,thebulldingw impnmonent issuld within oneyeare(completlun,the ownerbuild erwal have M burden ofproving that he did not build or improve for purpose of sale.), QTY, PLUMB GPERMIT FEE FLOOD ZONE APN LJ L as owner of the property,am exclusively contracting with Licensed PERMIT ISSUANCEcontractors to mrutruct the project(Sec.7054,Business and Professions Code: The Commences License Law don nu apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA) build. or Imp.thereon,and who coor ce, for such paojace with a FEE SUMMARY c9atIactor(s)Bcenaed pursuant to the Contractors License Low. RACK FLOW PROTECT.DEVICE LII am exempt under See. B k P C for this reasonOL)TSIDF FEES DRAINS-FLOOR,ROOF,AREA,COND. SANITARY Y_ N_ Owner Date RECEPf# •; WOR AN COMPEWSATION DECLARATION FEATURES PER TRAP SCHOOL TAX Y_ N_ ❑I hereby affirm that I have a certificate row of consent self-insure,or RECEITT# cedlfimteof Workers'Compematlonimumnmoramdifiedropythee f(Sec. GAS EA.SYSTEM-1 INC.40[JTLEI5 PARK FEE Y_ N= 3800,Lab C.) - RECEIPT Policy# GAS EA.SYSITNIOVER 4(FA) Com ray BUILDING DIVISION FEES chi oTedilled copybhereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCFIECK FEE 3s' ❑Certified copy Is filed with the city bupeRfon division. �- CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID rzli'D COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2WI+T ., Date Recei t# (This section and not be completed lithe perrrdt Isfor one hundred dollars ($10))or leas.) WATER HFATFRW/VENT•/ELECTR ENERGYFEE Y_ N_ I certify that In the pedormanceof theweek forwhlch this permit I.Issd, I shag not employ any person In any manner so as ro become abject io the WATER SYSTEM/TREATING Wwken'ComyynytlQryJ ,...f Iffomia.Date PAID �� •1)-[ � /')n•� O Z Applicent ((JJ_(xN1��LNN--''�s/s1 NE'W RCSIDLN77AL PLMB. SQ.FT. Date ReCei t J s/ Z O N017CET0 AI'PLIC :I, ermaking this Certificate of Exemption,you should became subject to the Workers'Compematlon provisions of the Labor TOTAL: 5D Cude,you rwat forthwith comply with such provisions arthis permit shallbe _ BUILDING E lL j domed revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE a Ilu,ebyaffirmthat there In a corstrob dion lending agency for the perform- TOTAL: ELECTRIC FEE Z anceoftheworkforwhichthis permit l309] eaad(See. ,CIv.C.) V O lander.Name PLUMBING FEE. H Lander'sAddreaeeae R QTY. MECHANICA FEE LL MECHANICAL FEE O PU I mAifythatl havemadt bapplicatlonand statethatthe above information laws eorred.Idgme to with all cityand county ordinances and pate laPERMIT ISSUANCE FEES PAID: 1 N relating to building construction,and hereby authorize representatives ofthls H Z city to enter upon the abevennantloaeci property for Inspection purposes. ALTER OR ADD TO MECH. Date Receipt# V — (We)agree to save,indemnify an d keep harmless the City of Cupertino against liabilities,Judgement,come;and expenses which may in anyway acme AIR HANDLING UNITETO 10,000 CFM) SUBTOTAL: a lost Id City Inconsequence of the granting of this molt 21 AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX Signature of Applicant/Contractor I Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZ.A RDOUS MATERIALS DISCLOSURE occupantWill the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,00D BTU) Date Recel t#' material as defined by the Cupedleo MunidpaI Code,Chapter 9.17,and the Health and Safety Code Section 75532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: O. ❑ Y. o )I WDlthe Applicant or lure building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE which emit hazardous air contaminants as defined by the Bay Area Air Quality Maoagemc strtct7 BOILER-COMP DHP OR 100,000 BTU) l-_AlQ ❑ Yes No [](] Ihave read the haze sus matedala requirements under Chapter G95 of BOILER-COMP roveR100,000 Bro) •Ju;,� 11 1.7JQ the California Health k Safety Cod,Sed iwa 25505,25533 and 25534.1 and erste rad that if building does not currently have a tenant,that It Is my NEW RESIDENTIAL MECH. SQFr. map am vfrt,dttherequisementawhlchmust1x mct EricDc,�s ifo panty. 'J� - PIItl of CU `m,a Owt -IC/� ULIMO_ Date•TI/ ISSUEDBY: JA TOTAL: OFFICE COPY