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19658 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES USE BALL POINT PEN ONLY Building Pm•ect Identification "" - PE"IT NO. Building Address: ._ 2 � -��.; �;�.'�-�•. - r 1.9658. OwnerName: Phone: p 'CITY OF CUPERTINO-BUILDING DIVISION " Z. ,`.+�• aQ O. ,r Ceat sNa - Un.No: .' APPLICATION /PERMIT O ^4 �(� BUILDING-ELECTRIC AGPLUMBING-MECHANICAL " CATEGORY CONTROL#. , Arch / gineer. _ Lk.No: ,r r:t• 1:'• ,•,.-BUILDING PERMIT WPO` ',R•` . QTYELBCT�2IC-PERMIT .lt s -.',tFEC t '. PERMITISSUANCE _ �. - 0 LICENSED CONTRACTOR'S DECLARATION, ' I hereby affirm that l am Licensed under provisions of Chapter 9(rommenc- APPLIANCESRESIDENTIAL JOB DESCRIPTION lnenseISection to.and dieon3 oflheguslnessandl'rofesslonsCode,and my '- t (cense lslns force and effect. PANELS ' License Claes' Lie# Date Contractor —UP TO 200 NTS - .'ARCHITECTS DECLARATION 2014000 AMPS P 9O I understand my plans shall be deec retar deed as publids. a OVER 1000 AMPS - SQ.FII FL RAREA - $/SQ.Fr. d6 Licensed Professional ' SIGNSELECTRICAL ` 6 w E7 OWNDECLARATION DECL ' - SPECIALCItCUIT/MLSC - , Ihereb amrmthction7 xem (romsa d Prefctor'sllcenee law(or the 2 O '� following reason.(Section 7 tto Business and Professions Code:Any dty or ' 0� TEb1P.MECER OR POLE(NST. , " G countywhsh requlresa psaiance,rovaWctIne.th,.proanystrucve,demoah,orenitto q "le asignerepriorto te.ranita Issuance,also req pursuant to provisions of to P64VER DEVICES LF5�O file a signed statement that he k Ikeneed pursuant to the provlsioru of the W3" Contractors License Law 9(commencing with Section 7")of Divi- ' Cin SWIMMING]Y30L ELECTRIC �0� sion 3 o the Business and Professions Cade)orthat he is exempt therefrom and VALUATION - y the Weis for the alleged exemption Any violation of Section 7031.5 by any OUTLETSSWITCHESFI%TURFS pis applicant fora permit subjects the applicant to a civil penalty ofect morethzn + [ m five hundred dollars($500) - NEW,RESIDENTIAL ELECTR STORIFS� ";TYPE CONSTRUCTION I,as owner of the properly,or my employees with wages as their sole SQ'T' C ¢ compensation,will do the work,and the structure k not intended or offered for. - ❑ sale(Sec 7044,Business and Professions Cade:The Contractors License Law $$ does not apply to an owner of property who builds or improves thereon,and. OCC.CROUP RFS.UNITS ' who does such work himselforthrough his own employees,provided that such Improvements are not Intended oroffered for sale.](however,the building or - TOTAL: improvement is sold within one yearofcomplelion,the ownerbudderwill have _ ov— tl nj_kunten o[proving that he did not build or improve far ur ose of sale 1 1 LJ L P R P purpose ) QT§::}- ,PLLIMBING$ER1141T 'l ,'."FEE:x - FLOOD wNE APN as owner of the property, Se exclusively Business ess acting with Ikeneed pFltMIT ISSUANCEi. ' The Contractor's ronLWctthe project(Sec.apply Business and Professions Code: �`� The Contractor's Lkenee law does net apply tn aowner oI property who +n' Wilda or Imprdves thereon,and who.rontracts'for each p(ojecta with a ALTER-DRAIN&VENT-WATER(piU ,0II.((actor(s)licensed pursuant to the Contractor's License Law, - ,d•" A {`.,FEE;$UMI1'fARY•:, y"x"�'a' LJ I am exempt under Sea B&P C for this reason BACK FLOW PROTECT.DEVICE J OUTS 11) FEES Owner .Date DRAINS FLOOR ROO$AREA,GOND. - SANITARY _i RECEIrf# WORANCOMPENSATIONDECLARATION FIXTURES PER TRAP - - SCHOOL TAX Y N' •. •❑[heKM reby affirm that I have a certificate of consent to self-Insure,ora " 1 # ..RFLF]Ixf# 3800,Lab C.) S . certificieofWorkers'Compernattonlneur5nmoracetlfledmpythercof(Sec. CAFA. WC.40IJTLEfS ' PARK FEE. Y_ T Policy p r - , ' '' RECEIPT# Com an GAS E- .SYSTEM-OVER4(EA) ., C' Y BUILDING DIVISION FEES Certfffed ropy I.hereby famished. - GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE ❑Certified copy N filed with the city inspection division. CERTIFICATE OF ECEMPFION FROM WORKERS' GREASE TRAP PAID tiCOMPENSATION INSURANCE ' SEWER-SANITARY-STORM EA.200Ff. Date ROCe1oo (fhisseaion need net W compleed If the permit ct forone hundred dollare ($100)or less.) „ WATER HEATER W/VENT/ELEC172 ENERGY FEE -Y N I certify that In the performance of the work forwhich this permit lc Issued, , I shall not emplo rson In any Per e�hm� ubject to the WATER SYSTEM/TREATING -aZrkers'Gom s 11 d a7O Z. NOTTC nt � �1%�ik � NEWRESIDENTIALPLMB.__SQ.Fr. PAIDDat2 RCtPI t#Z OF4S�' ICAN�"F: f,a er d gthimption,youbecomesulfic.to the Workers'Comp ofthe labor TOTAL: N Code,you moat forthwith comply with such provisions orthis permit shall beBUILDING 'E j' deemed revoked. - W CONSTRUCTION LENDING AGENCY SEISMIC FEE a (hereby affirm that there is a construction lending agency for the perfor ELECTRIC-FEE M Z ance of the work for which this permit is Issued(Sec.3097,Civ C) IOTA[ �. O O . I.endera Name x PLUMBING FEE' LL F Lenders Addrcea .. - "t QTY, i.MECR_ANICAL'-PERMIT .FEE MECHANICAL.FEE - " O W I certifythatl have read this appllratlonend smtethatthe abweln(ormatlon - iscorrect.l agree to comply with all city and county ordinances and elate jaws IPERMTT(SSUANCE FEES PAID: ' - 1 relating tobuldingcomtruction,and herebyau[horizerepresentativesofthfa - - - F—"W city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMFCH. •(We)agree to save,Indemnify an d keep harmless the City of Cupertino DBte p CefPtN ..V against liabilities,judgments,roateand expenses which may in anywayaceres AIR HANDLING UNIT 10,000 CFM) "SUBTOTAL: agains d sit, in mrsequja9ifithe granting oftMspern1 t. '1 /r AIRHANDLING UMT(OVFR iflotalcrAo,: CONSTRUCTION TAX ' G / r .Siglialsi re of Appllcant/ oatractor Dae E%HAf15'r Hoop(W/DUCT)" ' CONSTRUCTION TAX PAID: HAiZARDOUS TERIALSDISCLOSURE L Willtheapplimmorfuture building ocmpantstore or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCCCi IN material as defined by the Cupertino Municipal Code Chapter,9.12,ana the: �y� Health and Safety Coder.�Section 2S532(a)7 HEATING UNIT(OVER 100,000 BTU) - �°'� ITTOTAL: �{JI/ - ❑Yes u No Will the applicant orffium building occupant use equipment ordevices VGVrILATION FAN(SINGLE RESID). 'ISSUANCE DATE which emit hazardous air contaminants as defined by the Bay Area Air._ - I • Quality Management District? BOILER-COMP(3HPOR100,6w BTU) - I "✓ r / 1✓_ - ' 4Yes ❑No havcrcadthe hazard...materla requirementsudrChapter6.95o( BO LHR-COMP(OVII10,000 BTU) the Celifernia Health&Safely Code,Sections 25505,75533 and 25534.1 and ersta nd that if the Wilding does not currently have a tenant,that it fit my NEW RESIDENTIAL MUCH. SQ.FT. laltr responsibility to noldythe occupant of the requirements which must be met - O ` prior to issuance of a Certificate of Occu ^L pancy. 1 1�� Owner or authorized agent - Date , - 'l�sb l " I I'O'rAL: ISSUED BY:ys-+l%C14z\W.r • OFFICE COPY .