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20634 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Pro ed Identification PIERM7 NO. BuRllAddress: `uu1KM 20634 ours aame: eoM�uT one. APPLICATION SUBMITI AL DX= LE, CITY OF CUPERTINO-BUILDING DIVISION /' �^1 0 contr o•at Njme� _ l v4i uc.No: APPLICATION / PERMIT BUILDINCE7.ECLRICALMUMBINGMECHANICAL CATEGORY CONTROL# Ambitect/Engtnser. Lk.Nn QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO Addre�� 4AZL66TO/l) �. PERMIT ISSUANCE hl, ❑ ❑ LICENSED CONTRACTOR'S DECLARATION Ibereby affirmthal l am licensed under provisions of Chapter 9(commeru, APPLIANCESRESIDENTIAL JOB DESCRIPTION Ing with Section 7000)of Division 3 ofthe Budrmssand ProfesslonsCode,and my license heirs IIjj dPANELS fect /�( I License Cmss� Lie#' 'S S 3 S3lP lh/JrVy^` Date Contractor ARCHITECTS DECLARATIO 701-1000 AMPS gflq�<<��jjj + z l understand my plans shall be used as public mcords. OVERIODOAMPS SQ.FT.FLOOR AREA SM.FI. E� Limnxd Professional SIGNS ELECTRICAL OWNER-BUILDER DECLARATION �n SPECIALCIiCNT/MLSC •$OK1� D 2F• .7a IherebyatBrmtha[]amexamptfromthe Conlnctor's License Lawfmthe qo following reason.(Sectlon7ml5,Buslnessand Professions Code:Any city or FF'ry cauntywhkhrequlmapermittomwma,almnimprov demolkh,orrepar TF7.SP.MEIFR QRPDLE INST. g t'0 7 anysimmm prlorto lb issuance,alsorequlrestheappBcent forsuch permit to POWER DEVICES f5 file a signed statement that he Is Ikxnsed pursuant to the prowkuts of the 3ui.. Contractor's License Law(Chapter 9(oommencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION OJ slop 3 of the Business and Professions Cada)arthat he is exempt therefromand El I...777 the bask for the alleged exemption. Any violation of Section 70315 by any I UI7,E7SSW[TCHFSH%7T1RES 5 liapplicant fora permit subjects Ne applicant to a civil penalty of not morettan ve hundred dollars%500L NEW RESIDENTIAL ELECTR FT. LJ 1,as owner of the property,or my employees with wages as their sok STORIES TYPE CONSTRUCTION compensation,willelothe work and thestrurnrre is not Intended or offered for 2— In(Sac. le(Sec 70M Business and Professkra Code:The Contractors License law $ docs not apply to an owner of property who builds or Impmves thereon,and OCC.GROIIP RES UNITS who doessuchworklumselforthmugh hisownemployees,provided that such improvements arc not Intended oroffered for sale.If,however,the building or TOTAL: improvement is sold within one yearofcompletkn,the owner-builderwlll have tkgjIurdan of proving that he did not build or Improve for Purpose of sale.). QTY. PLUMBING PERMIT FEE LJ L as owner of the property,am exctusivdy mntratling with Ilcnsed FLOOD TONE APN contractors to construct the project(Sm 7004,Business and Professlom Code: PERMITISSUANCE The Contractor's Llmme Law does not apply to an owner of property who - Wilds or Improve thereon,and who contracts for such PPjeas with a ALTER-DRAIN k VENT-WATER(EA) ciamcimW Beamed pursuant to the Contractors License Law. FEE SUMMARY LJ 7 am exempt under Sec B A PC for this reason BACK FLOW PROTECT.DEVICE OUT91 DF FEES DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_Owner Data RFCFRPT# WORKMAN COMPENSATION DECORATION FD(NRES PER TRAP SCHOOL TAX Y N_ ❑I hereby all[ that I have•certificate of consent to self-Insure,or RECEIPT M certificate ofWorkers'Compensation Insurance ora certified copythereof(Sec. CAS EA.SYSTEM•1 WG.4 OUTLETS PARKFEE Y N 3800.Lab C.) RECEIPT M Polley p GAS EA,SYSTEM-OVER 4(EA) Com any BUILDING DIVISION FEES ❑pCertNed copy is heed with the GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE ❑Certified copy k filed with the city Inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM V.A.200FT Date Revel t# (This section need not be completed If the permit k forona hundred dollars ($IW)mless.) - WATERI{FAIFRW/VENT/EI.GCTR ENERGY FEE Y_ N_ I mrttfythat in the performance of the week torwhich this permit Is Issued, I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/YREA'HNG Workers'Compensation Laws of Callfamk.Dae PAID O Z Applicant NEW RESIDENTIAL PCMB. SQ.FT. Date Recel t# Z O NOTICE TO APPLICANT:I,after making this Certificate of Exemption, Fshould become subject to the Workers'Compensation provisions of the Labor TOTAL: N Code,you moat forthwith comply with such provisions or this permit shall be WBUILDIN 'P j deemed revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE (L Ihereby affirm that there Is aconstmetim kndingagency forihe Perform ELECTRIC FEE D Z anon of the work for which this permit k issued(Bec.3097,Civ,C.) TOTAL' . 02 Landers Name PLUMBING FEE ly, H LaMar'Addnm QTY. MECHANICAL PERMIT FEE' MECHANICALFEE OW lmdifythall have read thkappliatlonand stamthat theabove Information - - CL kcormct.Lag.to comply withal)cityand rountymdinanmand pate laws PERMIT ISSUANCE FEES PAID: >. relating tobullding construction,and hereby authorise representatives of this Ir— N city to enter upon the above-mentioned property for inspection P-Teles. ALTER OR ADDTOMECH. ? (We)agm to sue,Indemnify an d keep harmless the City of Cu portion Dale ReCci t# V agaWtllablliti dgments,costsand expenses which mayin any ya � a AIR HANDLING UNIT TTO 10,000CFM) SUBTOTAL: ag.imts i Iomm,!q. n The ting o(this perm it AIR HANDLING UNIT(OVER 10,000C III CONSTRUCTION TAX g of Applinnt/Cont m EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSU E Wlllthe%ppilcant or future buildingocuupant stare or handle havmlous BEATING UNIT(TO 100,000 BTU) Date Rc'oei t# material as defined by the Cupertino Municipal Code,Chapter 9.17,and the Health and Safety Code Section 75532(a)7 HEATING UNIT(OVER 100,000 BTU) 'TO AL: O q1 Yes q Na Ill the appliont or Lure building occupant weequlpment or devices VENTILATION FAN(SINGLE RES[D) 1$$ ATE which cool lav tonus air corm mlrants as defined by the Bay Area Air Quality Management District? BOILER-COMP OHP OR 100,00B BTU) - n' Yes F1 No JUN F 1 Ihave readthehazardousmaterials requlremenlsunderChapter6.95of BOILER-COMP(OVER 100,000 BTU) the California Health k Safety Code,Sections 25505,25S33 and 75534.I yyy...aaasss��a understand that if the building does not currently have a tenant,that It k my NEW RESI DENTIAL MECH. SQ.FT m . pPyy ni�m�yaT� responsibility to notify the occupant at the requireentswhich mu be t Rp11L 9� Priort su anre of a Certificate c_ ocy.OwK / n [O/1 70 er or out orlud agent 'Dat ISSUED BY:ZO�r tJ L TOTAL OFFICE COPY.