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22606r • 91 �— y ir 5 Wo a U_0 7 LL U Ow >(L F N z U- • APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Prom Identification Building Address© Pz P PERMIT NO. 260 6 2260 Phone. A C eL CITY OF CUPERTINOBUILDING DIVISION APPLICATION / PERMIT BUILDING-ELECTRICALPLUMBING-MECHAMCAL ��p` -1 C ctorsN. LI .Na: 1 .4/ `� �N CATEGORY CONTROL p t et,. LIc. No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address. PERMRTISSUANCE ❑ O ❑ LICENSED CONTRACTOR'S DECLARATION I herebyaffirmthat l amlkensed under provisionsofChapter9(commenc ingwith Seniors 7000)oforces deffeon3oflhe Buainessand PmfeselonaCode,and my license b Section full force and vislo APPUANCES.RESIDENfiAL JOB DESCRIPTION (� r. i (�r� PANELS LlmnscChss Lica Dae Contractor 201-100BAMPS ARCHITECT'S DECLARATION (understand nrypianashallbeused aspubllcrecords. OVER1000AMPS. SQ. FT. FLOOR AREA S/SQ. Fr. SIGNS ELECTRICAL Licensed Professional 11 IN N (��'l I VVV SPECIALCIRCUIT/MLSC OWNEReBUILDER DECLARATION Iherebyaff .(St atlame1.5.B.im..the dP.fContraners License Lawlor the follo�ntywhicaaon.(Se apen 1.5, Business and Professionse=le hnyntyor anyswcted stammentshathe I,ahensed ursuaat to the rovisi ns of t e anystm lmpr or4esaperMetoromtr-quimtheaphvntfrsuch,orrcpairtto a agned otaement that he h 1lcensrn pursuant to the pm of the ^ ax TEMP. METER OR POLE (NSI. f ppyyER DEVICESOle SWI MING POOL ELECTRIC DA I Contractors Llcenselaw(Clussionommn.ribut with Sernpitherefof Divi. 7000) Won 3 o(the 8uslnessand ProfessbnsCode)orlhat he hesnmpt Nerefromand VALUATION the basis for the alleged exemption. Any violation of Section 7001.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than OUTLETSSWTFCH4 MXTURES five hundred dollars (SSW. ❑ 1, as owner of the property, or my employees with wages as their sole NEWRESIDENEHALELECIR SQ}T. STORIES TYRPE CONSIRIKTION compensation, will do the workand the amen re b not Intended or offered for sale (Sec. 7014, Business and Pmfessioro Code: The Contractor's Llcerue law does not apply to an owner of property who Wilds or improves thereon, and who doessuch work himself or through hisown employees, provided that such OCC.GROl/1P RES. UNITS Improvements, arc not intended oroffered forsals. If, howevei,the W Ildingor TOTAL: Improvement beoldw thin oneycarofcompl&iogtheowner-buBderwill have tit,utden of proving that he did not build orimpmve for purpose ofiede.). Lf I, as owner of the property, am exclusively contracting with licensed comnctors m construct the project (See. 7044, Business and ProfessionsCode: QTY. PLUMBING PERMIT FEE FLOOD ZONE APN pggM)T ISSUANCE , The Contractor's License Law does not apply to an owner of property who Wild, or improves thereon, and who contracts for such ptojem with a �gBVactor(s) Bcenaed pursuant to the Contranorb License Law. IJ 1 am exempt under Sec B & P C for this mason ALTER -DRAIN &VENT- WATER (EA) FEE SUMMARY BAER FLOW PROTECT. DEVICE OUTSIDE! FEES DRAINS FLOOR, ROOF, AREA, COND. SANITARY Y_ N_ RECEIPT I Owner Date WORKMAN COMPENSATION DECLARATION sat( -In, ora ❑1 hereby affirm that I have a certificate of consent a mrc certificate of Workers Compensation Laurance or a certified copy lhemof(.See. 3800, lab C.) FI%Tl1RES PER TRAPe'1... CX) '4'1-7 SCI3OOL TAX Y_ N_ RECEIPT 8 GAS EA. SYSTEM -1 INCA OUTLETS PARK FEE Y N — RECEIPTX PolicyS p cram any GAG. EM SYST-OVER 4 (PAI BUILDING DIVISION FEES CertlRed copy h hereby famished. ❑ Certified copy h filed with the city inspection division. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE GREASETRAP CERTIFICATE OF EXEM PTION FROM WOR KERS' PAID EA 200FT COMPENSATION INSURANCESEWER-SANITARY-STORM (rhbsection need nor be completed if this permit b forone hundred dollars (E100)orbasd I certify th.t in the perf°manm of the work forwhich this permlt Is hound, Date ReCCI t# WATER HEATER W/ypN7yp-EC7R ENERGY FEE Y_ N_ WATER SYSTEM/TREATING I shall not employ any person In any manner m as to become subject to the Workers Compenaationlaweof Califomh. Data PAID NEW RESIDENTIAL PLMR SQ.FT. Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should became subject to the Wmken'Compen uti. provisions of the Labor Date Reoef t# TOTAL: BUILDING FEE Code, you most fort hwith comply with such provisions or this permilahall be deemed revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE I hereby afflrenthat there hacovhuction lending agency for the perform- ance of the work for which thin permit h issued(Sec.3 ,Civ. C.) Lender's Name LendereAddreas I certify thatl have read lhbapplicationand statethattheabove Information rrect. Ragreetocomplywith alletyand countymelimmorsand state law. TOTAL 2 a ELECTRIC FEE PLUMBING FEE A1C 'S QTY. MECHANICAL PERMIT FEE MEC(-IANICAL FEE PERMIT ISSUANCE FEES PAID: relating to building construction, and hereby authorize representatives of this city to enter u Pon the abovnersorioned property for inspection purposes. give to save, Indemnify an d keep harmless the City of Cupertino ag gmtl 6111) ,judgmeo cost sand expenses which may in anyway accrue ALTER OR ADDTO MECH. Date RCCeIJJt# AIR HANDLING UNIT (170 I0,000CFM) SUBTOTAL: ag Irst id I in .an cis of gr gof this permfe. AIR HANDLING UNIT (OVER 10,000CFM) CONSTRUCTIONTAX igmtum of Applicant Contra or Date MIAUSTHOOD(W/DUCO CONSTRUCTION TAX PAID: D HAPAR OU ERIALS DISCLOSURE Will the a ppecant or future building occo pant store or handle hanrdous Date ReceI t# HEATING UNIT (TO 100,000 BTU) - material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Healthand Safety Cade Sectlon255320)7 ❑ Yes No Will theapplicant or wm1xvilding occupant use equipment or devices HEATING UNIT (OVER 100,00(1 BTU) TOTAL: L� VFNILA DON FAN (SINGLE RESID) ISSUANCFPATE which emit hav rdous air contaMvnts as defined by the Bay Area Air Qua Iity Management Dist rin7 Yes No have read the li.q s materials requirements under Chapter 6.95 of said J" BORER -COMP (31 1POR 100,000 BTU) BORER-COMP(OVER 100,000 BN) the California Health &SafetyCode, Sections 25505, 25533 and 75534. I understand that if the building does not currently have a tenant, that It is my a tofOcothe notifytheoccupantofthe requirementswhich mustWrrct the occupant •} '(syelcH� cA.a s� NEW RESI DENTAL MECH. S'Q.FI. poor to issuance ce racy. poor to Lssuancc ofay cate ISSUED BY: Owner or authorised agent Date TOTAL: OFFICE COPY