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19825 APPLICANT.TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PFILWT NO. Building Address:© a� (�(�f"1 r 55� /`1 TEo/' -,- I9785G5c Mser came: Phone: A A � e(F /E 2sp,F/ ��-p�7/ CITY OF CUPERTINO-BUILDING DIVISION centraan.aNam: e__ Le. e: APPLICATION /PERMIT p E� t� y 3/ BUfLDING-Fd.ECIRICALPLUMBING-MECHANICAL CATEGORY CONTROL M Architect/Engineer. Lk.No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address; /-41//�� E �p PERMITISSUANCE IY71 ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION I�_I I hereby afflrmthat lam licensed under prwWonsof Chapmr9(cnmmena APPLIANCESRESIDENTIAL JOB DESCRB4ION Ing Mth5edton7OBO)of DiWsion3ofthe Budnessand ProfessunaCode,and my license l.ln fuu fo d effect. d-1, Y� PANELS Licenu Class Lk.N Date .- Contractor UP TO 2DOAMPS 2014000 AMPS ARCHITECT'S ATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT. �0 I understand my plans shall dull be used a public records. !z d(O�vj Licensed Professiowl SIGNSELECTRICAL Fd OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC I hereby affirm that 4 am exempt fromthe Contractor'sLicense Law(orthe 0 F9� following reason.(Section 7031.5,Bunsineand Professima, Cade:Any dry orF ilTEMP,METQt OR POLE INST. cauntywcmcfamapermttocostroct, ter, nproveemob ,orrepair mm anystrecurc pectin its betance,aborequirmtheapplicant forsuch permit to POWER DEVICES n;a Ole a signed statement that M b licensed pursuant to the provialons of the ((jjOc- Contractor'sLicense Law(Chapter9(mmmnncingwith Section 70M)ofDivi-p; In SWIMMING IDOL ELECTRIC O mebasis fo he alleged Profession. Any violhaheb Sum therefrom and V .DATION Q 5 the basis far the illeged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESH%TURES applicant fora permit subje o the applicant io a civil penaltyof nR nnre than IIJJVV Ove hundred dollars($500. R I,as owner of the roe NEW RESIDENTIAL ELECTR SQ.Ff. STORIES TYPE COh'STRUCTIOh' 2 ❑ property,rta or my employees r their comIn(Sec.7 on,wiRclothe Business aworkandthestruciurebmHntended License Law p do.n t.ppy Business ow er of Prefel.ru Co WildeContractorsthe. law does not apply to an owner of p rough who builds to improves thereon and OCC.GROUP RES.UNITS whodoements amssuch netm BormrougM1Nsow aleph owevrthebrildingyces,provided that ch s� improvements sold intendneyeared fcomprsaie.i(hmvevegt cterwdl have TOTAL: Improvement is sold within oneyearo(campiction,the owner-bu0derw111 have tkekurden of proving that he did net bred or Improve for purpose of sale.). QTY PLUMBING PERMIT FEE "L as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN rentradurs to construct the project(Sec.704y Business and Professlons Code: PERMIT ISSUANCE The Contractor's License Law does net apply to an owner of property who Wilds or Improves thereon, and who contracts for such pSojects with a ALTER-DRAIN&VENT-WATER(EA) gN(actor(a)hmnwd pursuant to the Contractor's License Law. FEE SUMMARY cffl am exempt under Sec B &P C for this reason BACK FLOW PROTECT.DEVICE— OUTSIDE FEES .r DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_ . Owner Date RECEIPT T Of"h certificate COMPENSATION DECLARATION FL%'IVRES I'ER TRAP SUI100L TAX Y_ N_ I(Qnemby affirm that I have acertificateons rate of cent to self-Insure,ora RECEIPT Y ani(Icam of Wrolums Compensatton4ruurance ora certified copythemo((Sec. GAS EA.SYSTEM-I WCA OUTLETS PARK FEE Y N 38M LabC�)/��I /� RECER NX PolicyaWr.016/p3is/s3 Q/7 GAS FA.SYSTEM-0VERd(FA) BUILRDZEBTDING DI VISIONFEES Com anv /-r / 444jmr.� [�Ce�tR1 c here homfiud: GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE rl Fified copy b filed with the city inspection division. CERTIFICATE OF.E%EM PTION FROM WORKER S' GREASE TRAP PAID COMPENSATION INSURANCE SEWERSANTTARYSTORM EA 2OOFT Date Reeei til (Thlssenion need not W completed R the permit b forom hundred dollars (S100)or lcss3WATER HEATER W/VENT/ELE.CTR ENERGY FEE Y_ N_ I cerily that N the perfarmanm olthe work forwFJch tMs permit b issued, I shall not employ any person In any manner so as to become subject to the WAT02 SYSTGI/TREATING PAID Workers Compensation Laws of California. Date O Z Appllemt NEW RESIDENTIAL PLMB. SQ.F , Date Reatf til Z O NOTICE TO APPLICANT:If,after making this Certificate,of Exemption,you should become subject to the Workers'Compensation provisions of the Labor TOTAL: N Code,you most fort hwlth comply with such provisions or this permit shall be BUILDING FEE W > m deeed revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE ISa (L e I herebyafflrmthat there bacomtructlon lendingagency(orthe perform TOTAL ELECTRIC FEE M Z ante ofthe work for which this permit b Issued(Sec.3097,Clv.C.) PLUMBING FEE 02 Lender'sName LLE' Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICALFEE O W] artifythatihavereadthbapplladonandstatmhattheaboveinformation bcormet.I agreeto comply with all city and county omdbrms and state laws PERMITISSUANCE FEES PAID: M mi,itingto Wildingmmtrudion,and herebyauthomorrepresentativesofthla F N citytoenterupon theabovc.mentkned property for Inspection purposes. ALTERORADDTOMECH. ? (We)agree to save,IndemN/y an d keep harmless the City of Cupertino Date Reecip[A V against liabilltks,Odgmeid,rortaand expenses which may In any wayamme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: ago Wt said City in mraequeme of the granting of this permit. AIR HANDWNG UNIT(OVER 10,000 CFM) CONSTRUCTION TAX Sigruture of AppBant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Data Recel t# material as defined by the Cupertino Municipal Code,Chapter 9.12,and the I kallh and Sifety,Code n25532(a)7 HEATING UNIT(OVER 100,0DO BTU) TOTAL: F1Yes Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUA CE QAM which emit harardous air contamimnb as defined by the Bay Area Air d"/aY Quality Management DLL�i�ssthN�L BOILER-COMP OHPOR 100,000 BTU) p 3r'' 4have read me M1azardous mmuterlala requlrcmnnta under Chapter 8.95 of BORER-COMP(OVER 100,000BM I �rii� U J i.LiJ the California Health&Safety Code,Sections 25505,8M3 and 25534. I understand that if the building does not currently have a tenant,that it is my NEWRESIDEN77AL MIiCH. SQ.FT. respo 'bility to notify theoccv ant of th requLterne which must be met � �'f y.9r AIfl66 Ph t Owner or snore lof Tfi;e l;�(O nry. �57 Date TOTAL: ISSUED Lf TOTAL: OFFICE COPY