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20976 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification ficcaatiion PERMIT NO. Buad Ing Addre,s: O -cw`•' LAW$.-n 3 2 -20976, At LICAlIONSUK1,1111ALDATE L; ��r•�0CITY OF CUPERTINO-BUILDING DIVISION CoctlyqLR kfIC, 3�6APPLICATION / PERMIT CATEGORY CONTROL M BUILDINGELECTRICALPLUMBING-MECHAMCAL Architect/Engineer, Lk. o: QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO Address: PERMITISSUANCE {� ❑ ❑ . LICENSED CONTRACTORS DECLARATION Lf [hereby affirm7000)of amecen3 ofthe Business and Prof]upter9(cemmenc- APPLIANCISRESIDENTIAL - ]OB DESCREHON ingwith infion9,,mand ffecln3 o(the Bueineasand Pm(eegonsGode,and my I icense Is In fuB and effect. 3 4 TPANELS UP License a LicX l//-lF-{7_l\T1M7` Date ontnctor 200 AMPS ARCHITECT'S DECLARATION 201-IMO AMPS D COC I�y�d�y(�a eused u publicrecards. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FI. Llcen,ed Profeage 1 SIGNS ELECTRICAL OWNER-BUILDER DECLARATION SPECLILCIXCNT/M7SC foll Z 1 herebyafflrmthatlimexemptfmenthe Contractors License Lawfarthe p owing reason.(Section 7031.5,Business and Profession Any or Code:An city OZ BusinessTEMP.METER ORPOLE INST. cauntywhich requiresaperMtlomrutruct,alter,bnpmve,dennlbh,orrepalr any structure prior to its Issuance,Alan requires the applicant for such permit to POWER DEVICES file a signed statement that he is licensed pursuant to the provisions of the 3O{-. Contractor.License Law(Chapter 9(mmmencing with Section 9000)of Divi- sionSWIMMING POOL 3 of the Business and Professions Code)orthat he is exempt therefromand VALUATION O the basis for the alleged exemption. applicant Any tViolationcivi of Section 7031.5 by any 1 �O a t applicanthudred apermit subjects the appllcanttoacivil penalty otnot room than OUY'LETSSW[TCHESHXIT7RFS L fivehundred1,as owner of he pr. SQ STORIES TYPE CONSTRUCTION �I,as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELECIR Ff. mmpensatfon,Mlldothewwk,andtheatmmmre naHtendedor offered for sale(Sec.apply to an owner fpropsWre Co Wilds Contractors LIcene Law 3� doe.not applyro an owner of property who Wilds orImproves thereoM and whodoessuchworkhimselforthroughhiaownemployeegprovidedthatsuch OCC.GROUP RES.UNITS - improvements ars,net Intended or offered fee sale.If,however,the building or TOTAL; improvement is sold within oneyearofcwnplelbn,the owner-builderw111 have tlgurden of proving that he did not Wild or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE,contncmrs to rontruct the project(Sec.7614,Business and I'mfeaabn Code: t The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) Wilda or improves thereon,and who contracts for such ptojects with a c%tfahcu(s)licensed pursuant he the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY ec LJ I am exempt under SB &P C for this reason Owner Date DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y_ N_ RECEIPT X WORKMAN COMPENSATION DECLARATION - pIX�ygES PER•[.RAI' SCHOOL TAX Y_ N hereby affirm that I have a certificate of consent to self-Insure,ora RECEIPTNX iflcateofWorkem'Comperogion I uurancewacerti(ledoopythersof(Sec. GAS F.A.SYSTEM-1 INC<OUIILEIS 3800,Lab CJ /O/7,ryx/ [//1 PARK FET? Y_ N_ Po11ryX 7 (l.L�l' 7V GAS EA,SYSTEM-OVER4(EA) RECELL''TX Cam any BUILDING DIVISION FEES [�Certifed copy la hereby with the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE . •Y�`Certified copy Is Ned y fu the city inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 20OFI Date Recef t# ffhisecction need not permit)(the pedt bforon hundreddollars ' (5100)orlyth WATER HEATER W/VENT/ELECTR ENERGY FEE Y N I artilythat the person nceny manner so as to become a witHe 6o the I shall not employ any person In any manner ro m to become.abject to the WATER SYSTEM/TREATING Workers'Compenatlon Laws o(CaB(omia.Data PAID O Z Applicant Date Recei t# Z O NOTTCETO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFF. should become subject to the Workers''Competaation provisions of the Labor TOTAL: W Code,you Most forthwith comply with such provisions or this permit shall be W > deemed revoked. BUILDING FEE C� G CONSTRUCTION LENDING AGENCY SEISMIC FEE 1 I hereby affirm that there is a mnttroctlon lending agency forthe perforto- ELECTRIC FEE Z ance ofthe work(orwhlch this permit labsued(Sec.3097,Civ,C.) TOTAL: 02 Lender's Name - PLUMBING FEE u. F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE U Icertlfythatl have read this applicatio..adgafethattheabove Information 0 W is correct.I agmem comply withal)city and county ordinances and gate laws PERMITLSSUANCE FEES PAID: } 0. relating tobuildingoonstruction,and hereby authorize representativesofthis )— N city to enter upon the aWvcmentioned property for inspection purposes. ALTERORADDTOMECH. ? (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt# V against liabilities,judgm.n .Aa dexpenseswhichmayinanywayaceme AIR HANDLING UNIT CIO 10,000 CFM) SUBTOTAL: r again Ci m en he granting of this permit q0 AIR HANDLING UMT(OVER 10,000 CFM) CONSTRUCTION TAX nate IApplirant/ ontocior Date EXHALE HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant atom or hand le hazardous HEATING UNIT(TO 100,000 BN) Date Recei [# material as defined by the Cupertino Municipal Code,Chapter 9.12,and the - ,�yt Healthand SafetyCodea2hion 2:532(a)1 HEATING UNIT(OVER IMM BTU) TOTAL: t Jv Ye. applicant 1011 i No VENTILATION FAN RESID) which emit emit hasarousa torebuilding as deflatuse the Bay Area devices ISSUANCE DATE whicM1emithazardom air contaminants as de0ned by the Bay Area Air Quality Mangement t 7 BOILER-CAMP OHP OR 100,DM HIM PA!® 4Yes o M1ave read the 1, a us materials requirements under Chapter 6.95 of BOILER-COMP(OVER100,000 BTU) ��` �� the California Health&Safety Code,Section 25505,25533 and 25534.I - understand that If the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH.. SQ}T. r/ responsibility to notify the oca ant of the requirements which must W met , prl o ua Is ifkat ( ccvpanry. WSJ atcup@t no S! q0 Owner or authors dagent ate 75c - TOTAL: ISSUED BY: V VQ�BC)r'•'a OFFICE COPY