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21793 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification Iiul�ldingOA.0 y, Cis /sI aI 7 9^ ' ' 'hm 1 !S/� one: G I 1{/ CITY OF CUPERTIN0.6UILDING DIVISION _ - O C,. c°ntndar.N. ue.N°, APPLICATION I PERMIT C lie "o ` sCATEGORY CONTROL N Archlted/Engineer. Lt.No: BUfLDINGELECTRPCALI'LIJMBINGMECF1AhTCAL QTY ELECTRICPERMIT 'FEE BUILDING PERMIT INFO Address: PERMITISSIIANCE .DD 1:111L 1 1 El LICENSED CONTRACTOR'S DECLARATION 4-� Ihereby thvedion7 )ofDat I ivlicensedheunder Busiemand.of mnslmsr9(mmmme- MPLIANCESRF.SIDENRAL JOB DPSCRFFION IngwRh Sedlon force and f Divfect. (the Buslnessand ProfesalonsCode,and my ' LI...is in full force endd(ect. PANELS, V,Dale - Contactor - �.V • ARCHITECPS DECLARATION 201-ODD AMPS PQ±reO ZO- I understand my plats shall be used as public records. OVERIODOAMPS - SQ.FEFLOORAREA $/SQ.FT. E Licensed Professional - SIGNS ELECTRICAL - OWNEDECLARATION R-BUILDER In a zThereby afRrm thatm l aexempt from the Centrador's Llmnse LA.for the SPECIALCB2CUIT/M1SC ppp following reason.(Section 7071.5,Business and Professions Code:An cit or F county whm ichmqulre.a permit to nstroct,alteq Improve,demolish,or repair TEMP.METER OR POLE INST. - anystructum prlortu its lesuance,also requirestheappllcant(orsuch permitto file a signed Yaterrcnt that he b licensed pursuant to the provialo a of the POWER DEVICES _ O w Coal.=License law(Chapter9(commencing with Section 7000).f Dlvl. 30 akm3 ofthe Business and Professions Code)orlhat hebexemptthercfromand SWIMMING POOL ELECTRIC VALUATION fh ..777 the basis far the allegedexem"k. Any vialaHon a(SMlon 70315 by any applicant for a permit subjects theappgcanl to a civil penalty of not more than OUILETSSWITCHESFIXTURES live 1,as demodeltathe property, SQ, STORIES TYPECON5IRUCTION 4 µ NEW RFSTDENTIAL ELECTR Rf. td �n ❑I,asownerll theewor",orhe eocrayeeswithwagesa their sole or e .1.03acompensation,0K Ihotinc New Professions ions Code: h not Intended or censeofferL w - 5' sale(Sec appy to anowandf property Code:The orImproves s License law doesoessunot ch wornownerofpouraghisonempoyees,povidedthat and OCC.GROUP RFS.UNITS 0.0. whodoementsa net Intended rough hlsowale.If oweveovidedlklogor - Improvementearenotlntendedoroftreed(orsale (he o neer-builderwitlbve TOTAL: Improvement V sold within oneyearo(compldiory the�wner-buiWerwlll have tl,Lkurden of proving that he did not build or improve for purpose ofsalN. QTY. PLUMBING PERMIT-, FEE FLOOD/ONE APN - LJ{as owner of the property,am exclusively contracting with licensed contncton to cerswct the projed(See 7014,Business and Professions Code: PERMIT ISSUANCE ` The C.Meactorb License law does not apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA) Wild. or Improve.thereon, and who contract; for such ptaajecta with a c' adoKs)licensed pursuant tothe Contractors Lia.Law. FEE SUMMARY 61 am exempt under Sec. B k P C for this mason BACK FLOW PROTECT.DEVICE Owner DRAINS FLOOR ROOF,AREA.CON I. 'SANITARY Y N . .. • Date RECEB'T.N WORKMAN COMPENSATION DECLARATION IT)(NRES E'ER•CRAP SCHOOL FAX Y N_ pl hereby affirm that I have a certificate of consent to mif-morn,or a RECE PT M mKifimteof Workera'Compensationlns mnmo amrtlfid copythereo((Sec: 3800,Lab CJ GAS EA.SYSTEM-]INC.p OUTLETS PARK ITE Y N Poliry a GAS EA.SYSrEIvLOVRR p(EA) RECEIPT M raY BUILDING DIVISION FEES L^ertiOed copy b herebywith furnished. GREASE/INDUSIRL WASTEINTERCEPTOR PLANCHECK FEE �Certifled ropy billeddwith the city Inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCESEWER-SANITARY-STORM F.A.200177. Date Recai (# (This section need not be completed If the permit b forone hundred dollars (SIOD)orless.) WATER HEATER W/VENT/M.ECTR ENERGY FEE Y N I mrtlfythat In the performance of Ne work for which this permit is issued, — I shall not employ any person in any manner so as to become subject to the WATER SYSTGM/TREATING Works%Compensation laws.of Gllfornla. Date PAID O z Applicant NEW RESIDENTIAL PLMB, SQFr. Date Recei t# JZ O NOTICE TO APPLICANT:If, ki ,after mang te this Certl(iaof Fxemptlon,you should become subject to the Workers'Compensation provisions ofthe Labor - TOTAL: CC O) Code,you most forthwith comply wlthsuch provisions orthb permit shall be i' BUILDING 'E LU j deemed revoked. CONSTRUCTION it Fa ON LENDING AGENCY SEISMIC FEE CL .of th y affirm thatwork thcrebsconstrodlond(Seelending agency Civ. .) perform, ELECTRIC FEE D Z once of the work for which this permit bissued(Bee.3097,Civ.C.) � TOTAL:(-) 2 Lander.Name PLUMBING FEE IL h IarAcesAddrcss QTY. MECHANICAL PERMIT FEE MECHANICAL FEE OW lmdlfythatlhavemadthlsapplicaWn and Yrtetbat theabove information . IL 1.C. .Iagrce to complywllh all city and county ordinances and Yate laws PFRMITISSUANCE FEES PAID: .. } W relatingtobulidingconslructiory and hereby authorize representatives ofthis -. - f.. Z city to enter upon the above-mentioned property for inspection purposes. ALTIRORADDTOMFLH. (We)agree to anve,Indemrdfy and keep harmless the City of Cupertino Date Receipt# V against liabllllles,pd,roms,roti.and eapc..a which may inanywayaccrue AIR HANDLING UNIT(rO10,000CFM) SUBTOTAL: ago told In ronseq .04he granting ofthis permit. _�I AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX -81grWreo plimnt/Cantracior Dat EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE - - Wllltheapplicantorfumm building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) - materialasdefined by the Cupertino Municipal Code,Chapter 9.12,and the _ Date Reeei t# Ilealth and Safety Code Section 25532(a)7 I MATING UNIT(OVER 100,000 BTU) TOTAL: s Ye. Ir�-,I No - Will the appliantar(utum Jr.llding onvpart use equi proem or devices VENTILATION FAN(SINGLE RESID) , IS$�, [�J(, ypATE which emit hazardous air contaminants as defined by the Bay Area Air w6 � Qu lity M.nagemmtDistrld7 BOILER-COMP OHP OR 300,000 BTU) 'Ph Yes he ❑No Q 4havercad cabb&Safet Codefabrcqul 25505, 5533 ad of BOILER-COMP(OVER 100,000 BITJ), JAN 3 the California at lith k Safety Code, ofcurSection,25505ave a t and 2553t.1 _ - 14 ,• ' understand that notifyhe the occuing pant of herequir m nts tenant,that b b my NEW RESIDENTIAL MECH. SQ.FT F 0T tolIss a c mf a Certificate Occup.rcqulmmenb which most be rrret _ QW. blef (M ripe to Issuance o!a CertiOate of Ompanry. �$�r({{ Owner or authorized agent Data + of . TOTAL: ISSUED M1_4 i' OFFICE COPY