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20690APPLICANT TO FILL IN INFORMATION WITHIN RED LINES _ USE RAI L PnINT Ppm nmi v - Building Project Identification - - Bullding Address: a�a - - - — PERMITNO. Ol6 uJ /� ^ O wnere Name, one: •. CITY OF CUPERTINO-BUILDING DIVISION / PERMIT BLJILDINGELECTRICALPLUMBINC-MECHAMCAL A ' - Contra " rm: Lie. N.APPLICATION ell hJ V Arc lied/Engineer. Lk. Na CATFCARY CONTROL M QTY ELECTRIC PERMITFEE' BUILDING PERMIT INFO Address: _ r PERMITISSUANCE - LICENSED CONTRACTOR'S DEC [hereby dflrtnthat lalicensed under providonso(Chapter9 (comment- Ingwlih Section70fA)om f DiW$1=3ofthe BudnenandPrvfe-sion4Codgand my license Is In full form and effect. License Cissa Date .Contractor ARCHITECTS DECLARATION I understand my pIs--bell be used as public records, - . Prfemloml DECLARATIONSPECIALC]RCUIT/MISC I hereby affirm that lam exempt from the Contractor'. License Law for the m...(Sedeon 7031,5, Businee-aad Professions Code: Any city or7'p�(P•ML-TLP requires a permit tomartruat, alter, Improve, demmllah, orrepalr anyatmu mPrbrtoitsism-a.,alaorequim.theapplimntfwsuchpert ttoppWp((DEV[CESfile a signed statement that he is licensed pursuant to the provlslone of theGntrsetm'e License Law(Chapter9(commendngwithSedbn7000)o(Divl-gWEs(M(NC Ccal0rrthat he is exempt therefromand the basis for the dinged exemption. Any violation of Section 7031.5 by any applicant fora permit subjects the applicant to a civil penalty d not mo -than five hundred dollars ($500). ❑ I, as owner of the property, or my employeea with wages as their sok rompensatlon, will dothe work, ad the structure'. not intended or offered for sale (Sec. 7094, Business and Prni.ioes Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who does such work himenforthrough his own employees, provided that suchOCC,GROUP Improvement-arenotintendedorofferedfo ole. If,however,thebuildingor improvementissold Mthln oneyearofmmplelon,theowner-bu0derwillhave t)akurden of proving that he did not build or improire for purpose ofsxkJ, LL�J L an owner of the property, am exclusively contracting with licensed rontndon to comstructthe project(Sec. 7046, BusMem and Profeasloru Code: The Contractor's License Law does not apply to an owner of property who bu Bds or Improves thereon, and who contracts for such p4oject- with a cgB�T�dor(-) licensed pursuant to the Contractor's License Law. LJ I am exempt order Sec. B 6 P C for this reason APPLIANCES -RESIDENTIAL PANELS JOB DESC ON -,yt,iLQiCJ(/�J 201-1 (100 AMPS OVER 1000 AMPS. SQ.Licensed SIGNS ELECTRICALOWNER41TILDER 'following ORPOLE INST.cmuntywhich POOL ELECTR[Gslon3oftheBuelneeeandPro(eskm OUTLETS -SWITCHES -FIXTURES NEW RESIDENTIAL ELECTR SQFI, STORIES TYPE CONSTRUCTION _ RFS. UMTS TOTAL; QTY, PLUMBING PERMIT FEE' PEgMI.I.ISSUANCE ALTER -DRAIN & VENT -WATER IEA) FLOOD yp �N BACK FLOW PROTECT. DEVICE FEE SUMMARY Owner Date - DRAINS -FLOOR ROOF, AREA, COND.- - FIXTURES. PER TRAP SANITARY Y_' N - RECEIPT R WORKMAN COMPENSATION DECLARATION' '❑I hereby affirm that'I have a certIDcate of consent to self -insure, or a rediflcate of Workers'Compemationlrmumnce or a certi(ird mpythereof (Sec. 3800,Lab C.) Policy M TOOLTAX Y_ N_ RECEIPT a CAS EA. SYSTEM -1 INCAOUTLtiM - PARK FEE Y_ N_ RECEIPT p It Com any - GAS EA, SYSTEM -OVER 4(EA) BUILDING DIVISION ION FEES [�CedlEed copy is herefiled w tumbhrd. �Cedlfird copy M filed with the city Irupedlon division. CERTIFICATE OF E)(EMPIION FROM WORKERS' COMPENSATION INSURANCE need not becompleted lithe perirdt bforuns hundred dollare (SI IIO)orlenJ lax I cent that employ an prexa in any manner so as tobehis permit c booed; I shake not employ any Person in any manner so as to become subject to the s'Compensadon Laws o(GmM llfa. Date Applicant Applicant NOTICETOAPPL9CANT:I,aRermaking this Certificate of Exemption, you shoutdbecomesabject to the Workers' Comperudeonpervinkme.fthe Labor Code,yrurwst(mthwlth comply with such provision or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY - Ihercbyaffirm that them be ones on kndingagenry for the perform saw of the work for which thin permit b bsund(Sec, 3097, Civ. CJ Lender's Name Lender'.Addirss I ced lfy that have read this application and state that the above information iscorred.I agree to compiywitb all dtyand county ordinances and state laws relating to building construction, and hereby authorize representatives ofthis citytoenterupontheabovamentinned property for Inspection purposes. (We) agree to save, Indemnify an d keep harmless the City of Cupedlno against habllities,judgments, costaand expenses which may in anywayaccrue against old City in roniryuence of granting of this permit. .. Sigwtun of Applicant/Crntredor Date HAZARDOUS MATERIALS DISCLOSURE Willtheapplicantorfuture building occupant store or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.1$ and the hkxlth and Safety Code .a �No-.Section 25532(.)7 F1 Yes . u . Will the applicant or future building occupant use equipment or devices which endt hazardous air contaminants as d.fined by the gay Area Air Quality Management District? Yea ❑ No `Thavc read the hazardous materia'. regoirements under Chapter 6.95 of the GllfornM Health A Safety Code, Sections 75505, 75533 and 75534. I understand that lithe building doesnot correctly have a tenant, that it is my responsibility to notify the occupant ofthe requirements which must be met prior to issuance of a Certificate of Occupancy. �. -Mr-20 GREASEANDUSIRL WASTE INTERCEPTOR PLANCHECK FEE PAID . Date Recei [# GREASE TRAM' - SEWERSANITARY•STORM EA 2001717.(Thlssectlon '. WATr.RHF-ATERW/VENT/FLECTR a 06 - ENERGYFEE Y N PA ID -+ - + 'Date Recei t# + WATER �" M/712�T(NG NEWRESIDENTIALPWILSQFI'. - TOTAL: U NG FEE - TOTAL: // Ori 7 SEISMIC FEE ELECTRIC FEE 'QTY. MECHANICAL PERMIT FEE PERMITISSUANCE - ALTERORADDTOMECH. - AIR HANDLING UNIT (17010,000 CFM) PLUMBING FEE MECHANICAL FEE FEES PAID: • Date - ' Receipt# SUBTOTAL• MR HANDLING uNrr fcivaR June am) DIHAUSTHOOD (w/DUCT) CONSTRUCTION TAX CONSTRUCTION TAX PAID: - HEATING UNIT (TO 100,000 BTU) - 'Date REC'ei f# HEATING UMT(OVER 100,000 BTI!) ' ' TOTAL:`, VENTILATION FAN (SINGLE RESID)fd64010EDATE- x IiKW6. p q OCT - . riT 31%1 90' , �jj4(ss�(�' ' -� O!DUE$" ' ISSUED BY: "`�+'� 1''r�••', BOILER-COMP(3HP OR 100,000 BTU) BOILER-COMP(OVER 100, 000 BTU),-'�4J NEW RESIDENTIAL MECH. SQ,FT. - Qwner or authorised agent - Date TOTAL: OFFICE COPY