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19397 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN'ONLY Bulletin Pruart Identification + PERMIT NO. Banding Address: Or E Rj^ ,� o I_�D 19397 -IRUIPneve am. Phone: q CITY OF CUPERTINO�BUILDING DIVISION Conmactoi.Name: Lk.No: APPLICATION I PERMIT Architect/EnRI ee n r. BUILDING-ELMMCA PLUMBING-MECHAMCAL CATEGORY CONTROL ?6� Lle No: J r' QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Aaareee:G,e.MPBfiU— CAr 9P51 PERMI7755UANCE FICIMI LICENSED CONTRACTOR'S DECLARATION 11 I hereby affirm that l am Become!under provisions of Chapter 9(commeno- APPLIANCES-RESIDENHAL JOB DESCRIPTION ingwith Section 7000)of DlWslon3oftheeualneamod ProfessioneGdeand my license Is In fun force and affect. PANELS License Class Cmdr ��` Date Contractor ARCHITECTS DECLARATION 201-10DOA.ARPS q�+�'OL Cl understand my plans shall be used u mounds, OVERIODOAMPS SQ.FT.FLOORARFA $/SQ.FT. !C 00 Licensed Professional SIGNS ELECTRICAL OWNER-HUILDER DECLARATION SPECIALCERCUIT/MLSC 2s, a 1hereb (@ y. m thatIarn.mmpt from the Contractor's License Law for the ppppppfollowing reame.f5ection 7611.5,Business and Pmfemlons Code:An cityor F s' county which requlresa permit to commuct,alter,Improve,demolkh,orreair TEMP.METIRORPOLEINST. nystmci mpr rtoltsissuance,abomquireatheapplkantfwsuchper tto file a signed statement that he licensed pursuant to the provklom of the POWER DEVICES k r�(_ Contractors License Law(Chapter9(commencing with Section 7000)of Divi.ISWIMMING POOL ELECTRIC L, .:3J elon3 ofthe Business and Profemlom Code)orthat he k exempt therefmmand s VV El G the bask for the alleged exemption. Any violation of Section 70115 by any OVILETSSWITCHESFIXTURES applicant(or a permit eubjectothe applicant to a civil pemlty of nae more than five hundred dollar($50%. SQ.FC. STORIES TYPECONSTRUCUON O A ti NEW RESIDENTIAL ELECTR �I,s owmro/the prop",oche work, myemploymwith ended r offir ered fo compensation,will dothework endthe structure Code;The Contractors intended orofferedfor O die(Sec. ppyBan oveandfpropeom Code:Theorimp hemer,ense Gw �$ does net apply roan unser ofprough his own improovided thatand such — OCC.GROUP RES.UNITS who eve earsuch acorn t Intended ed oorthrough hlsown e.If,however, provided ilding or Improvement issuld intendeeyearoeredfordk.themmveg deer ill have TOTAL: ' Improvementkeoldwithinoneyeamfcampletbn,theowner-bullderwill have th9,Zurden of proving that he did not build or Improve for purpose ofsak.). QTy, PLUMBING PERMIT FEE FLOOD ZONE APN Lf L as owner of the property,am exclusively contracting with licensed contractors to construct the preject(See.70M Business and Professions Code: PERMIT ISSUANCE The Contractor's Liomm Lew don not apply to an owner of property who ALS-DRAIN kVENT-WATER(RA)bunds or Improve eon ther ,and who contracts for melt p(ojects with a FEE SUMMARY cg0lpctor(q licensed pursuant to the Contractors License Law. gA�pLOyy pROTFGT.DEVICE L-,J I am exempt under under SB k P C for this reason OUTSIDE FEES DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_ Owner Date RECEPr N WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y N C31 hereby affirm that I have•certificate of consent to self-insure,or a RECEIPT N mAlfiateofWnrkeraCompemati.i.rana or a certified copythereof(Sec. GAS EA.SYSTEM-1 WC.40UTLEIR PARK FEE Y H moo,Lab C.) RECEIPT N Pulley a GAS EA.SYSTEM-OVER 4(EA) Com any BUILDING DIVISION tF.fS �Ca Ified copy k hereby famished. GREASE/INDUS[RL WASTE INTERCEPTOR FEE []Certified copy k filed with the city impection dieblon. Cry CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID COMPENSATION INSURANCE SEWCR-SANITARY-STORM FA.2007r. Date Recel t (Thissection need net be completed H the permit k forons hundred dollars ($100)nrlem.) ENERGYFEE Y N Iartifythat in theperimmanceoftheworkforwhich We permitleksued, WATER HEATER W/VEM/©'ECTR L1—e I shall not employ any person In any manner an as to become subject to the WATER SYSI.FM/.TREATING ..���qq i W�' Worker'Compensation Laws of California. Date PAID ff,,{{..,, O Z Applicant NEW RESIDENTIALPLMB. SOFT. Date ReceJ t Q!W Z O NOTICE TO APPLICANT.If,after maong this CertHlate of Exemption,you should become sub)ect to the Workem'Compematlon provisions of the Labor TOTAL: fA Code,you at forthwith comply with such provisions orthk permit shall btBU W > deemed revoked. ' - d C CONSTRUCTION LENDING AGENCY SEISMIC FEE I hereby a Brat that there Is a construction lending agency for the perform- ELECTRIC FEE Z anceofthawmkfurwhkhthk permit at hmued(Sec.3097,CIv.C.) TOTAL' U O ]ender.Name' PLUMBING FEE LL 1= Iendcrs Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE OW I certifythatl havereacithk application and datethatlheabove fformatlon IL Occurred.lagreetocomply with.lldtyandmuntyordlnancesandalatebw. PERMIT ISSUANCE FEES PAID:, relating to building consemctnsion,and hembyauthorlu expresentativesofthk W H Z city to enter upon the abov irentlod property for inspection purposes. ALTER OR ADD TO MECH. Date Rl IN z (Wa)agree to save,Ind courtly an d kep harmless the City of Cu perttso eveP sgaiat liabilities,judgments,costeand expenses which may In any way... AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: against mid City in consequence of the granting of this permit. AIR I-1ANDLINc 1)N1r(OVER 10,000 CFM) CONSTRUCTION TAX Signature of Applicant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building Occupant store or handle huardous HEATING UNIT 00100,ODO BTU) Date ReCel tM materkl as defined by the Cupertino Municipal Code,Chapter 9.12,and the d't Health nsd Safety Code,9ediion2S532(a)i HFATING UNIT(OVER 100,000 BTU) TOTAL. No 111 the applicant MOO O building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE mi which et haaa rdout air contaminants by the Bay Area Air �p911 Qua Illy Mae.gement District? BOILER-COMP OFR'OR 100,0(0 BTU) _ 111 No LCL 4hYeavereadthebuallousmaterialsrequiretentsunderChapter6.95of BOILER-COMP(OVER 100,000 BTU) � � the California Health k Safety Code,Sections 25505,25533 and 25534.I Ps JO I understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. ' SQ.Fr. I' responsibility to notify the occupant of the requirements which must be met (!�}r a,� prkO(Oissuanceofa CerUOate of Occupanry. -14};P! (.11n?rtino Owner or auehodaed agent Date TOTAL: SSUED BY: OFFICE COPY