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19547 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Pra'ext Identification PERMIT NO. Building Address: 1 Z i ` (o ✓ f fAoA 15 PD C l7L , I seers 1—me Phone: A A cA If 4-7 CITY OF CUPERTINO-BUILDING DIVISIONAm _ D eontraetoraName: Lie.K& APPLICATION / PERMIT LIc.N. BUILDINGELECnUCAI PLUMBINGMECHANICAL CA RY CONTROLM��O Mteyt/� n r. (7,� QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO Akh7 01—ICOIW AY PERMITISSUANCE 1s� MITH LICENSED CONTRACTOR'S DECLARATION I hereby affirm that lam Bcensed under pmovislonsof Chapter9(commenc APPLIANCESRESIDENRIAL BDCSC ON IngwithSMlon 7ODO)of Division3ofthe Buslnessand PmfeaslonsCode,and my LiceraseCla.in ll fora and effect. PANELS 1 �'ie� license Cyan Liff c NII V Date Contractor LTIQZMAMPS r\ — 74 ARCHITECT'S DECLARATION W_SQj S reO Zp I understand my plow shall be used as public records. MPS SQ.FT.FLOOR AREA 5/SQ.ET. U(D Llrenud Professional RIC L C ' / / - ell- < OWNER-BUILDER DECLARATION CU[ o l4,' !hereby affirm that l am exempt from the Contractors License Law for the 0...'a following reason.(Section 7031.5,Business and Professions Code:Any city or /F�F'� muntywhichrequlresa permulocomutrua,alterlmprovedemolbh,compair TDA OR 7� anystmumprmrtoltslssuame,alsorequimstheappllrantforouchp.r tto !file a signed statement that he b licensed pursuant to the pe,vislov o! theContractor's License Law(Chapter9(commencing with Section 7000)of Divi- Lslon3 of the Business and Prefesslons Code or that he b exempt therefromandVALUATIONlitydS thebasb for the alleged exemption. Any t tolabn of Semon ex31.5 by a y pZ r /{%o r (JappBantforapermlt subjectstheappllcanttoacivllpevlty o(not morethan t0 � ofive hundred dollars(,M. �I,as owner o!the property,or my employees with wages as lM1elr sale AL � SQ� STORIES TYPE CONSIRUCt10N k < compensation,will do the work and thestructume in not Intended or offeredfor I $ O Is(Sec.7014 Business and Proferosslons Code:The Cmdractols Llttrue Law V $ does not apply to an owner of property who builds or Improve thereon,and who doessuchwork him elf orthruugh hisownemployees,provided that such OCC GROf1P RFS.UNITS ImprovementsarcnoHnlendreyearfnredfor sale.throwevcgilderwdingw TOTAL: �? / improvement am not tintnded or ffecompletion,theowe,verthebuilll have t Iden of proving that he did not build or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE pLoG, zoNE APN L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE contractors to amearect the project(Sec.7014,Business and Profenlmis Code: The Contractors License law does not apply to an owner of property who x Wilds or Improves thereon, and who contraM for such pAojech,with a ALM-DRAIN k VENT-WATER(EA) cc tt[[actor(s)Ilmnsed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY LI[am exempt under Sec B k P C for this reason Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ NOuTsin� . WORKMAN COMPENSATION DECLARATION RECEBxTp 01 hereby affirm that I have a certificate of consent to self-insure,or F7%TURFS TER TR AP 't(A SCHOOLTA% Y N cxniflate of Worken'Compevation Insurance ora certified copythereof(Sec. RECEIPT# 3800,Lab C.) GAS.EA.SYSCEM-1 INCA OUTLETS TT PARK FEE Y N Policy# Ot/ RECENT# Com any GAB-EA.SY9TQ OVER4(FA) BUILDING DIVISION FEES HCenified copy b herebyfurnished.the city GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE �CenJed ropybfibd with the sty inspection division. Gu c CERTIFICATE OF IXEMPDON FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE (rhiswdt nneednmt completediftheper tbfmonehundreddollan SEWER-R-SAMTARY-STORM EA.20017T. Date Retmi t# ($100)ar len.) WATER HEATER W/VENT/ELECT# ENERGY FEE Y N I cenlfythat N the performance of the work forwhich this permit is based, I shall not employ any person in any manner oto as to became subject to the — Worken'Compensation Iowa of Callfornla.Date WA'C[Bt SYSTEM/TREATING PAID O Z Applicant //'' //`` Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDEN7IAL PLMB. SQ.FT, Date Recei t# ppb cc should becorcraubjeett.the WmIxers'Campensatlon provisions of the Labor WW Code,you most forthwith comply with such provisions orchis permit shall be TOTAL: > deemed revoked. B ILD NG -E .C-0 d p Consrgurnons LENDING AGENCY , SEISMIC FEE , I hereby affirm that there i a construction lending agency forthe pedorro- Z aneeofthework for which this perMlbIssued(Sec.3097,Civ.C.) TOTAL: .0ELECTRIC FEE 0 L Q LL O Lenders Nam PLUMBING FEE LL h- Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE O W correct. I hatl agrees comply with aliationanddc state ordinances information 4 is to comply with all and county and state laws PERMIT N00 FEE-PAID } N relating to building nstruction,and hereby authorize representatives of this N co Z city to enter upon the above-mentioned property for Inspection purposes. r ALTERORADDTOMECH. - (We)agree to save,Indemnify..d keep harmless the City of Cupertino `� Date Receipt# against liabilities,judgments,costs and expenses which may in anywsyace,on AIR HANDLING UNIT(TO 10,D30CFM) against said City in consequence of the granting eff this permit. SUBTOTAL: AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX Sigmture of AppBant/Contractor Data IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will theapphant or future building occupant store or handle hazardousHEATING UNIT(TO 100,000 BTT!) materials,defined bythe Cupertino Municipal Code,Chaper9.lZ and the r Date RCCej t# I lcOalt Yesd Safety Code,Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) ❑ TOTAL: ) Will the applicant or town,building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE which cared hazardous air contacdnsnb as defined by the Bay Area Air a J @+ Illy Management District? BOILER-COMP pHPDR 100,IXD BTI!) 4 Yes No have read the Nazar us materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000BN) �t ps{��� the Calilornla I lealih h Solely Cade,Sections 7550.5,75533 and 25534.I rBn understand Out lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. '^=L responsibility to notify the occupant of the requirements which most be met ^ ��ry Prior to Issuance da CertiOate of Occupancy. JJ� `t Owneror awize hord agent Date `'+ pyo 1ys� l TOTAL: ISSUED BY:w`�'�IlY7t— Lm ,[ OFFICE COPY