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20788 APPLICANT TO.FILL IN INFORMATION WITHIN RED LINES — USE,BALL POINT PEN ONLY Building Project Identl8catlon _ - PERMITN�O Budding Address: © I G L Nd S )s. r°Name: one: A 788 !�^ CITY OF CUPERTINO-BUILDING DIVISION - 7 aJ 00C ne°d°'° Lm.No: APPLICATION /-PERMIT T .2 BUILDING-ELECTRICALPLUMBING-MECHAMCAL : CATEGORY CONTROL# Ar .hest/Engineer. Lie.Na ' / QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Addres 2smG f J t O(Y. PERMITISSUANCE [:1 -o ❑ LICENSED CONTRACTOR'S DE RATION I hereby affirmthat l am licensedunder provisions of Chapter9(ammenc. APPLIANCESRESIDENTTAL JOB DESCRIPTION d1 Inlwith5eon7m0)of DlWelon3o(the BuatnessandlProfesatovCode,and my - licen�eislnfu❑❑(o , // PANELS < Licence Cbss(i" Lk.N q6 - DateLIP TO 200 ANTS CQ 0 C HITS dr ARCHITECPS DECL blit ne OVER00 AMIPS q�vreO Zp ]understand my plans shall be used as public reconls OVER 1000 AMPS SQ.FT.FLODR AREA S/SQ.FT. "19 Licensed Professional SIGNS ELECTRICAL gOWNER-BUILDER DECLARATION z� Iherebyaffirmthat lamexempt fromthe Contrors actLirence Lewfar the SPECTALCIRCUTT/MISC po following reason.(Section 7031.5,Bu.iness and Profession.Code:Any city or 02 TEMP.METER OR POLE INST. countywhmpriorlresa pemdttoanstmuirestheaprovgdemolish,ornotto " �11 anya signore statement that he Is also req pursuant to ro wionsch of t e POWER DEVICES - rG c. file a actor's statement that het licenced pursuant it the provisions of the - OContractor's License Law(Chapter 9 Commencing with Section here)of Divi- S%TMMING POOL ELECTRIC VALUATION F,30a the bs(the forthen ss alleged Profemion.Anyvirthatheiseectionherefromand - a.•,]] the bash for the alleged exemption. Any Woladl of Section.a by any OUTLETSSWITCHFSFIXIUREg appilantfora permit aubjedetheappBcanttoaciWl penalty of oat more than � D five hundred dollars(1000). SQFI',� RIES IYPECONSTRUCTION A - NEW RESIDENTIAL ELECTR WWW p^, ❑I,an owner will the property,or he employees with wages ss offered sole fo compensation,Boston.. workand thestmdure isnot Intended o iofferedfor O ale(Sec.70K Boniness and Proo erty Code:The Contractor's License Law does$ and who's applytoan imserofproperty who nempoyees,povided taRhat uch OCC.GROUP RES.UNITS whodoementsa arkhimsendedoroughhis ow ale.lf owcprovidedildiogor improvementnarena intenmeyeof(fr mpraiae th,h ser-r,thebrwilI have ' TOTAL: Improvement iseokl wlthlnoneyearo(compldloRtheowner-bullderwlll have the_*rden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE OZONE APN u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE ontradors to construct the project(Sec.7044,Business and Profession Code: The Contmdor'.License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) builds or Improves thereon, and who contracts for such pkojed - a with a FEE SUMMARY c.6actmis)licensed pursuant to the Contradoes Licence Law. - BACK FLOW PROTECT.DEVICE I am exempt under Sec B&P C for this resson OUTSIDE FEES DRAINS FLOOR,ROOF,AREA,OOND. SANITARY Y N Owner Data RElrpp WORKMAN COMPENSATION DECLARATION FIXTURES PER.TRAP SCHOOL TAX Y_ N_ ❑I hereby affirm that I have o lmurate of concent to py thsure,Cg a RECEIPT N 3800,m�ffiabofWorkern'Compensadontnsurana ora certi(led ropy thereof(Sec. GAS E.N.SYSTEM-1 INCA PARK FEE Y N 3800.Lab CJ - - RECEIVE# Poiiry X GAS FA.SYSTEM-OVER4(FA) Com any ,(Z jassr 1 BUILDING DIVISION FEES Certified opy ishereby th the city —T+ GREASE/INDUsr2L WASTE INTFRCEPTnR' PLANCHECK FEE ❑CertNed ropy is filed with the city inspection dlvlMon. � ' CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID„ NCE SEWER-SANITARY-STORM EA.2Wh7'.INSURANCE(Thos section need not be completed the perSURA isforone hundred dollars Date Recei t# (81Io)mless.) COMPENSATIONWATER HEATER W/VENT/ELECTR ENERGY FEE Y N ' Icertl(ythat In the pedornunce o(thework forwhlch this permit is issued, -- I shall not employ any person in any manner so as to become subject to the WAIII{SYSTEM/TREATING Workers'Compevattonlawsof California.Date PAID " ZZ Applicant - NEW RESIDENTIAL FILMS. SQFI. Date - Recei t# O NOTICE TO APPLICANT:If,after making thin Certificate of Exemption,you should become subject to the Workers'Compensation provisions of the Labor TOTAL: Code,you most forthwith comply with such provisions or this permit shall be - BU LDING FEE' W > deemed revoked. CL 5.00 CONSTRUCTION LENDING AGENCY SEISMIC FEE - Iherebyaffirm that there is a construction lendingagency forthe pedorr, TOTAL: ELECTRIC FEE :3Z Bance ofthe workforwhichthis permit is Issued(Sec.W97,Clv.C.) 02 Iander'.Name PLUMBING FEE IL I— Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE OW 1artifythatl haveread thlsippecaH.nand x1atethidtheabove information , a Is correct.I agree to complywith all cityand county ordinances and Mate laws PERMIT ISSUANCE FEES PAID: >. N relating to building construction,and hereby autherlu repremntatives of this city to enterupon the above-mentioned a for inspection purposes. ALTER OR ADD TO MECH. ~ Z ty(We)agree save,Indemnify an d keep harmless the City of Cupertino Date Receipt# V against liabilities,judgments,costs and expenses which may In any way amue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: against said City In cunsequence of the granting of this permit. Ate HANDLING vNrr(OVER 10,000 CM) CONSTRUCTION TAX Signature of Applicant/Contractor Date EXHAusr HooD(W/DUC'D 'CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will theappllantor future building occupant More or handle haurdous HEATING UNIT(TO 100,000 BTU) Date ReceI t# material as defined by the Cupertino Municipal Code,Chapter 9AZ and the Health and Safety Codedlon 25532(a)2 BEATING UMT(OVER 100,000 BTU) TOTAL: Q 1 1 Yes No Will the applicant cWtum building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) J$$[Jtopa'J'F, which emit ba,cardou°air contaminants as defined by the Bay Area Air a lity Management DBtr/d2 BOILER-COMP(3H P OR]00,0(10 BTU) ' Iii ' yea �fNo Thive readtheh.,YusmaterialsrequiremenounderChapter6.95o( BOILER-COMP(OVER 100,000 BTU) / the California Health&Safety Code,Sections 25505,75533 and 25534.1 understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. r mo coal ity to notify the occupant of the requirements which at be met City.01 t•UD(:{aI�I,� i toosman a rtlficateof Occupancy. - (00 r. ora thoared agent 0 /Data - Issue B UI G� TOTAL: OFFICE COPY