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19655 -APP LICANTTO FILL IN INFORMATION WITHIN RED LIN_ ES - USE BALL POINT PEN ONLY " Building Project Identification I a PERMIT NOO - Build' g Address: . '1:9655 era ami:" - . .Phone: - -- LEwi� Z (Z�1JG CITY OF CUPERTINO-BUILDING DIVISION L_" q0 cemo- m<: uc.Ng: APPLIOATIOWPERMIT L BUILDING-ELECTRICALPLtIMBING-MECHANICAL.', CATEGORY. - r CONTROCp ' A ect/Engineer: Lic.No: FEL ' ' ` _IL_DINC PERMIT.INFO' - QTY i;x EEE07RICtPEkMITt ., '4 Address: �� PERMITISSUANCE ❑ ., •❑ ❑ ., LICF.NS DCONTRACTOR'SDECLARATION'". ' I hereby affirm that lam licensed under pmehaons of Chapter 9(rommenc- APPLIANCES-RESIDENTIAL, JOB DFSCRI'HON- ' ingwlth SectkmM00)ef DlWaon3 ofthe Bushossand ProfesslonsCode,and e • license i-in tint force and effect my PANELS ` Llanse Class LIc.N` I I Date 1, ontractor - - w �, —_ j,S F-',.��,f 1 �• ARCHITECTS DECLARATION, 201-1000 AMPS' _ . oZ 4 I understand my plam shall bensed as public records. OVERIOOOAMPS ;SQ FT.FLOOR AREA $/SQ.Ft. O Licensed Professional ' SIGNSELECTRICAL w OWNER-BUILDER DECLARATION `N61 rSPECIALCItCUIT/MISC Ihercbyaf6rmthatlamexempt from the Contractors License Law for the _ OO following mason. 7671.5,Business and Professions Code An cit or J OZH Y Y TEMP METEROR POLE(NST.' Py c ntywhichrequiresaper ttocomtmct,altepimpmwde lleh repair gmm anyatmemro prior to Its issuance,alsorequiresthe appliuntfor such permute POWER DEVICES L5 K file a signed statement that he is licensedd-pursuant to the provisions of the - Q6 3 u, Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- -VALUATION "ib aon3 of the Business and Professions Code)orthat he is exempt therefrom and SWIMMING IY)DL ELECTRIC O,� the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLFTSSWITCHFSFIXTURES applicant for a permit m ut sublecsthe applicant to a civil penalty of nore than five hundred dollars($500). NEWRESIDENTIALELECTR o ❑I,as owner of the property,or my employees with wages as their sale SQ.FF. STORIES TYPE CONSTRUCTION - 7a compeneation,wilidothework•andthestmetumisnotintendedoroffercdfor A D. sale(Sec.7044,Business and Professions Code:The Contractor's License Law ��.. does not apply to an owner of property who builds or improves thereon,and s w who doessuch work himself orthrough his own employees,provided that such OCC.GROUP - RLS.UNITS. Improvements are not Intended oroffered foraale.If,however,thebuilding or TOTAL: ��� I i peovementbsoldwithln oneyearofcomplellon,the owner-budderwill have - ' 'tfe�¢urdenofprovmgtnatha did cot build orimprove for purpose of sale): Q77 *'• �'' 'PLCIINBINOPERMFT t' ,..FEE"` FLOOD ZONE ArN uu I,as owner of the property,am exclusively contracting with licensed ppD.ISSUANCE I^x co f contractors to mnstruct the project(Sec.7054,Business and Professions Code: < The Contractors License Law does net apply to an owner of property who ' ALTER-DRAIN&VENT WATER(EA) Wilds or Improves thereon,and who contracts for such projecx,with a - .-t` „ktti c actor(-)licensed pursuant W the Contracture Llanm Law. - BACK Flow PROTECT.DEVICE . i+',�•ii 55r `1F ESUM161ARY ". L�I am exempt under Sec. B&P for this mason ' .• Owner "- " Date DRAINS-FLOOR ROOF,AREA,COND. SANITARY Y'm (IceFD(TURF_er N=, _ WORKMAN COMPENSATION DECLARATION PER SCITOOL LAX Y RECEIPT'If N ❑I hereby affirm that I have a rti te of consent to-self-Insure,or RECEIPT N certificate o(Workem'Compensation Insurance or a certified copy thereof(Sec. GAS EA. WC_.4 OUTLETS PARK FEE Y— N_ 3800,Lab CO - Policy It - RECEIPT M Co .. GAS -OVER4(FA) - .EY BUILDING DIVISION FEES, Certified copy is heed with the cit: GREASE/INDUSTRL WASTE INTERCEPTOR ' PLANCHECK FEE ' ❑Certified copy is filed with the city inspection divlsl n'� ` CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID' COMPENSATIONINSURANCE per ANCE SEVVER-SANITARY-STORM EA.2WFT. Date Receipt# �(TM1is eectignneed notWENSATI NtI SURAmit istoren-hundred dollars '($IW)or less.) WATER IiEA77R W/VENT/ELECTl2 ENERGY FEE Y N' a I rtifythat In the performance ofthe work for which this permit is Issued, " I shall not employ any peexon in any r a m as to b me subject to the WATER SYSTEM/TREA77NG (� rY - Workers'Compe o sof Callfo Date O �t , PAID Z ApplicantNEW RESIDENTIAL PLMB. SQ.Fr. Date'' Recei tit t' Z O' NOTICE I. 46.f,after t Ifi=to of Exemption,you 'F should becomesubject on to<he Workere'Compe provlaons ofthe Labor - .TOTAL: W Cod,you musiforrthwith comply withmmit provlslons orthis permit shall be a � > deemed revoked. _ BUILDING FEE LU p CONSTRUCTION LENDING AGENCY - - SEISMIC'FEE ' Ihereby affirm that there is a construction lending agency for the perform- 0 CJ ELECTRIC FEE 7 onceof the work for which this permit is issued(Set,.3097,Civ. TOTAL t V O Lector's Name I I I Ix PLUMBING FEE LL f, Lender's Address - QTY' •: MECHANICAL"PL2MIT , n4FEE;' MECHANICAL FEE ' O W omet. tagree have reedy is with allcitign and state thattneabovedgateaa MECHANICAL building comply allcityhe byaunty homse inancts ropreseaativeselaws PERMIT LSSIIANCE FEES PAID: '} U) rulacityt oenterupongcenstmctioryandhereby authorizepectiontativeso(tM1la ' F.. W city to the,Indemnify an pmpeharml.Wpe Cit purposes. ALTER ORADD TO MECH. ? (We)aired to save,Indemnify an a keep harmless the City of Cupertino N - Dale 'Receipt# V against liabllltiea,judgmenterset and expense which may In any wayaccme AIR HANDLING UNIT CFO t0,f00 CFM)' SUBTOTAL: agalnstea consequence granting of this pemniL - - " �� AIR IiANDUNG ilNrr(OVER1B,rnB CFM) . f . CONSTRUCTION TAX ra o Applicant/Contractor r _ Data EXHAUST HOOD(W_/DUCT) CONSTRUCTION TAX PAID: _ HAZARDOUS MAT ALS DISCLOSURE - ' Will the applicant or future building ocmpantsbur or handle hazardous• - I-(EATING UNIT(TO 100,MO BTU).` Date - Recei t# material is defined by the Cupertino Municipal Code,Chapter 9.12,and the _ 'I-fealthand Safety Cede SNoectlon2S532(a)?' - HEATING UNIT(OVER 100,000 BTU) Ye - TOTAL• I :©D ❑ ' Will the applicant orfutum building occupant use equipment or devices " VENTILATION FAN(SINGLE RESID) "1$SUANCE�DATE which emit hazy rdous all cents"nants as defined by the Bay Area Air - - r . Qu a hty Management District? BOILFR-COMP(3II'OR 100,000 BTU) - . Yea ❑nNo ' -' y ( CF4Y have read the hazardous materials requlrcmenls underChap(er 6.95 of BOILER-C.0 the Califernia I lealth&Safety Code,Sections 75505,25533 and 25534 I, understand that ifthe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. - SCI I� flrltttry responsibility to noti(ythe occupant of the req.usco nlswhich must be met' ( '11�IlTth priorto Issuance ofa Certifidte o(Ompanry. 2-x'3 rjO Ow ner or authorized agent Date• r ISSUED BY. sr^t�W'�V�-•t,' •d - TOTAL: ,OFFICE COPY . . : r r