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20703 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Pm ea mendf cagon PERMIT NO. 8.1111.g Adare.a: � 20703 1bG3o S . CS/A.+ �� CIPC ? ✓ `15D/ Wrlere irM' TZ,' Anlq Opt-His 9 3124 CITY OF CUPERTINO'BUILDING DIVISION Gan' ar CI� "{Lk.N fG uG.N APPLICATION /PERMITall A ( ( U W BUB-DINC-ELECTRICALPLUMBINGTEGO MECHANICAL CARY CONTROL Y/_bq ? Itttt/Engineer. ,^/n' V AeRL� LICENt Addrces21 QTY ELECTRICPERMIT FEE BUILDING PEROMIT INFO xc SD CNCPERMITISSUANCE LARATI N I hthSb lfb7m00tDb)aotflDalmvli.3d(thi.Bwr.i n..O nao(Chapter9(mmmene AAPPLIANCES-RESIDENTIALlice.seei.f.11J .naGfect, dProresdonaCcellincimy PANELS Lic.8 ]OB DESCR)R' f1ON a C�Oats Contractor J.J O•xl��I xa�vaL./LIMY- 11 AiCHITECPSDEC RATIO 201-1000AMP5 l (J` �pp�uu mOQ I la my pia else u as public rerord. OVER 1000 AMPS SQ.FT.FLOOR A��R--E//..Aaa $/S'�Q..FT. Ltee, a tonal SIGNSELECTRICAL Z 7 I 6 OWNER-BOLDER DECLARATION SI'ECIALCIRCOT/MLSC t 2 F' � Iherebyaflrm tlutlamexemptfromlhe Contractors License law(or the O F following reason.(Section 7031.5,Buslneu and Professions Code:Any city or Py comtywhlch requbesa permittnmmtwct,alter,Improve,demolbh,urmpalr"TEMP.METER OR POLE INST. any strocturctatemethat he 1,licensed pursuant to thetfaauion,of pOWEIt DEVICES els a signed statement that he b licensed pursuant to the provlelom of the Contractor.License Law(Chapter 9(mm .d.gwith Setllon700o)ofDlvl- vi S sion3ofthe Busi mmdPr-f—I.m Cad ).rthat hebexemptthemfmmand SWIMABNG POOL ELE CO< the bast for the alleged secure a Any ttG atlon or Section 7031.5 re any OUTLETS-SWITCHESFI ES _I J SappllunHorapemdt$SM. she app8csntroa civil penalty o(notrrorethun ff—VALUATnIOlb C five]1,as ed owner of ( 5M. NEW R ENIT �n ❑I,asowneror theework,aormy employees with wages Ilanrot —�fT• [S 71TE CONSTRIX:TION compensation,c70K wuldolbe work end thesC dere b not Intended or offered for O sale(Sec.70Cy Business andlPmperty hobuiThelds Contractors Llama Law daea not apply to an owner olproperty who builds or lmprovm thereonand whodaessuchworkhtm lforthmughhlsownemployen,provided thatauch OCC.GROUP RES,UNITS Improvements are not Intended oroffered forsale.If however,the buliding m TOTAL: bnprovemembwldwltMnoneyearofcomplNioo,theowner-buBeb di have V the bumen o/pmving that Ae did out build or Improve for purpose ofsalaJ- QTy, P MIT FEG �J L as owner of the property,am exclusively mntracting with horn ad WOOD ZDNE AIN rontnctan to ronstmctthe project(Sec.7094,BuaNen and Pro(mlons Code: a P ANC , The Contractors Llan.Lsw does net apply to an owner of property Wild.or improves thereon, and who central,(or each pTofem wit a AL IN& -WATER ro actor(.)licensed pursuant to the Contractors Lk Law. FEE SUMMARY I am exempt under Sec B k P L (or fhb rtaw 9A T.DEVICE OUTSIT)"FEES Ow r Date D NS OOF,AFkA,COND. SANITARY Y_ N WORKMAN COMPENSATION DECLARATION RECEIPT M l I hereby.1111.that I have•arUBate of consent to self-Iowa,ora PERSCI1O0L TAX Y N artitlate o(Worken'Compensatlon lmuranceaa certified copy thereof07ec. RECENT N 380D,Lab G EA. STEM-1 PARK FEE Y_ N_ policy N 7 RECEII'P N Cre �"� A6 EA, d(EA BUILDING DIVISION FEES �Cedi ied ro by tumt ed. GREASE/W INTERCEPTOR PLANCHECK FEE Certified ropy b filed with the city Impaction division. CERTIFICATE OF O(EMPFION FROM WOR KERS' GREASE PAID_7'Ip�O COMPENSATION INSURA14CB (fhbsecticormil not W eempleted Btheperodt 6(oronehundred dollars SLIVER-SA AR RM EA. Date Recei t# (5100)otifyth ENERGYFEE Y_ N_ Iartlfy that In the performanaotthe wak farwMrh this permit isbwed, WATER Iff.A W ENT/FlFGTR l.hall not employ any person In any runner w u to become wb ed to the `7 •! f/ WATER SYST[M/TREA NO O Workers'Compensation Lawsaf California.Date PAID Applicant Z Q NODCETO APPLICANT:10fter making this—C-91—of Exemption,you NEW RESIDENTIAL PLMB. :n,El', Date Re i t# Workers'F should become subject to the Woe 'Compensation provisions ofthe Labor t pl Code,you=at forthwith comply with such provlelons orthb TOTAL: permit shall be W > domed revoked. BUILDING •O4 (LO CONSTRUCTION LENDING AGENCY M L_ = Ihercby a(flrtnthat theretaromtwctlan leadingagency for the per(orrry TOTAL: once olthe work forw�kh/qts 11 issued(sec,3097,Civ.C.) W 1 LL 0 lender.Name LLF Lender'.Addre.a QTY, MECHANICAL PERMIT ITE EE a O W Icertilythatl have aadthlsappliatlon and matelhatthe above ln(ormatlon G'� 4 tcomxt.lagrccto comply wkhallcttyand muntyaminaam and statelawa PERMITLSS'UANCE 11c� } N relating to building mnstwRion,and hereby.whodze representatives o(this 2 H U) city to enter upon the above.mentioned pmperty(a inspection Purposes. .0. ALTER OR ADDTO MECH. (� (We)agree to save,Indemnify an d keep harmless the City of Cupertino t Receipt# V agaWtBabilltin,judgmen metsandexpenseswbkhmaylnanywa .arae AIR HANDLING UNIT(TO 10,0D0CFM) UBTOTAL• jag City In con na o renting of this pet 471 AIR HANDUNG UNIT(OVER 10,fDOCIM) CONSTRUCTION TAX o pp am/Con ractor Dat pxxnuST HOOD(W/DUCT) CONSTRUCTION TAX PAID: AZARD MATERIALS DISCLOSU Etheappll nt or future uitcing occupant store or handle havardous HEATING UNIT CIO lODODO RTU)la.defric by the Cupertino Municipal Code,Chapter 9.12,and the Date ReceI t# Here lth a rad Safety Cade ton 25532(a)P HFATING UNIT(OVER 100,000 BTU) TOTAL: ❑ Yn No Will the applicant forum building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE whichemithamttlous Ir mnleminantsas defined by the Bay Area Air QualltY�mgemnnt Di BOILER-COMP OLIN OR 10,000 BTU) lr No d 4b.vereadthehaz o mate cls equirement under Chapt¢r 6.95 of BOILER-COMP(OVER 100,000 BTU) p �(] the Calllarnla Health Safety Code,Sections 25505,25533and 25539.I 9a !# N �x7JO undentaM that l(t building does not comnily have a tenant.that It b my NEWRESIDFNTIAL MEIN. $QFI. I r respomibility,to notify the occv a oItherequ ment which must be cost priorlo da Certifloeu cups 041 at 0i WWUt Owner a re a t arc ISSUED BY: "✓ TOTAL: OFFICE COPY