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20859 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY BuildingProject Identification PFRMITNO. Ba 1117F R 6i" 01 O/L 20859 6 dnC: OGG: �,(, � CITY OF CUPERTINO,BUILDING DIVISION Qa. /• �O G r.n°""/'"4,G:v uG.N°, APPLICATION / PERMIT C- JI^���`7TNS 6 BE LDINGELECTR CAL(LUMBINGMECHAMCAL CATEGORY CONTAOLN ArcbltW/Engineer. Lic No: QIY ELECTRIC PERMIT FEE' BUILDING PERMIT INFO AddM99 7'FRMITISSUANCE ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION Thereby af(im,thetlam licensed under provisions of Chapter9(rommmc- APPLIANCESRFSIDENTIAL JOB DESCRIPTION ingwlth Se&ion7OW)of Dlvision3ofthe Busineeeand ProfenlonaCWe,end my license Is In full rce and effect. PANELS at Contractor ' ARCHITECT'S ECLARATI201-10W AMPS PQ+ O I understand my plans shalt be used as public records. OVER 1000 AMPS SQ.FT.FLODIR ARIA $/SQ.FT. E obE Licensed Professional SIGNS ELDCTRICAL ul DI OWNER-BUILDER DECLARATION SPEC IALCiRCUIT/ ZL, a son(hereby affirm that l sexempt from the Contractor's License Law for the O ... following reason.(Section 7MI.S,Business and Professions Code;Any city or TEMP,METER OR]'O FSI county which requires a permit to construct,alter,Improve,demolish,or repair �Gany structure prior to its issuance,also requires the applicant for such permit to ppSVER DEVICES K Ole a algned statement that he is licensed pursuant to the provisions of the Gj O Contractors License law(Chapter 9(commencing with Section 7000)of Divi- SWIN&MBPOOL ELEC cion 3 ofthe Business and Professions Cods)orthat he b exempt therefromand VALUATION the dials for the alleged exemption. Any violation o(SMlon 7031.5 by any < the fcrapermited exe ption. Any of Ss Joaf not morel hon OUTLETS— TGIiFS IS L�W fiv�undred dollars(550)). 1,as owner of theproperty, NEW REST AL EL STORIES TYPE CONSTRUCTION 7< ix,a or my employees in with wages r their sole compensation,vellidoth¢work,anaelma, odure Isnot Intended oroffered(or O sale(Sec. pply y to alnowandf property Code:The Wilds orimproneContractors License Law doeanotsuchoan owner ofproughhisoeemporimprovvidedtatand 0.0. impmvewhodocntsamnkh tededolf roughhisownemploowevrthebthatauch OCC.CROUP RFS.[RJH'S Improvementsarenotintendedoroffeco (orale.If,h ne,r.gtheerwilI have TOTAL: Improvement isaold withinoneycar°fcomplellorytheowner-bu0derw111 have tfo*rden of proving that he did not build or Improve for purpose ofsale.). QTY, PLUMBING PERMIT frE FTAODTANE APN Lj L as owner of the property,am exclusively contracting with licensed ppf.f.ISSU�CE contractors m censuuct the pro)ed(Sec 7044,Bualnass and Professn ioCode: IIs Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VEN7- bullds or Improves thereon,and who contracts for such pT*u with a WATER TA) �( dor(s)licensed pursuant to the Contractors License Law. gpCIC FLOW PROTECT.DEVICE FEE SUMMARY c L_f I am exempt under Sec B& P C for this reason OUTS I UP FEES Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N WORKMAN COMPENSATION DECLARATION RECEIPT N QI hereby affirm that 1 have a Mrtifiate of consent to self-insure,or a FD(TURES PER TRAP SCHOOL TAX Y N artlflate of Worken'Compensatl°n Insunnaora Mrtifled ropythemof(Sec. RECEIPT M 3800,lab C.) J GAS-EA.SYSTEN-1 WC.40VILI:TS PARK FEE Y_ N P°11cy It '6 RECEIPT N Com any__�r _ --- CAS EA.SY5TEM-OVER4(EA) BUILDING DIVISION VISION PRE5 �C°rtl(led copy is heed with the ed.city GREASEANDUSIRL WASTE INTERCEPTOR PLANCHECKFEE �Ccrti(led copy is(14d with the tlty Wpcctlon division. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE (Thlssectlonneed not becomplcled lfthepermit isforonehundred dollars SEWER"SANITARY-STORM EA.200FT. Date Receipt# ($100)orfess) WATER HEATER W/VFNT/ELWTR ENERGY FEE Y N performance that the perfounof the work for which this permit is issuM, I shall not employ any person In any manner an as to become subject to the WATER SYSTEM/TREATING Workers'Compensation Lawn of California. Date PAID O Z Applicant Z p NOTICETOAPPLICANT;If,after making thisCertificateof Exemption,you NEW RESIDENTIAL PLMB. :n.IT. Date Recei t# N should become subject to the Workers'Compensation provisions of the Labor TOTAL: Code,you=at forthwith oomplywith such provieursorthls perndtshall he W > deemed revoked. -BUILD[N s a Z CONSTRUCTION LENDING AGENCY SEISMIC FEE Z 7 hereby affirm that there Is a construction lending agency forthe perform ELECTRIC FEE anceo(the workforwhichthb permit is issued(Sac.3097,Cie.C.) TOTAL: O O lender'.Name PLUMBING FEE IL F Lender`sAddr°sa QTY. MECHANICAL PERMIT FEE MECHANICAL FBG O W Icedifythatlhdvemadtbis application patethattbe above Information 1 bcorma.I agmeto comply with act city and countyoofloanmand state[am PERMIT ISSUANCE FEES PAID: W relating to building mmtmctton,and hereby authorlu representatives of this U) city to enter upon the above,mentioned Property for Inspection purpose, ALTERORADDTOMECH. Dare V — (We) a to sq�a, a n d kap harmless the City of Cupertino Receipt# agairstl bl tl-a,jTa(me s cad expenses which may In any wayaccrve AIR HANDLING UNIT(fO 10,000 CIM) SUBTOTAL,al i City con a the gra nun of this permit AIRHANDUNG UNIT(OVER 10,000CFM) CONSTRUCTIONTAX r S' ria fApplHAZARDOUSor L D(ITADST fI00D(W/DI1CT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE — Wllltheappllantorfeture building occupant store or handle hazardous HEATING UMT(TO100,000BTU) Date Recei t# material as defined by the Cupertino Municipal Code,Chapter 9.12,and the H71 vend SafetyCode,Seg)ion 15532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: ♦ O Yce No Will theappbcan tum building occupant use equipmentordr ice. VENTILATION PAN(SINGLE RESID) ISSUANCE DATE which emit hazard sair ntaminants as defined by the Bay Arca Air ' Quality Mawgement Dis ct7 BOILER-COMP pFI'pR l00,Om BTU) Yca No P�rh have read the ar oua rtuteriais requirements underChapler 6.95 o! BOILER-COMP(OVER IOD,000BN) - V4Ji the California Heath&5afetyC Sections 25505,25533and75E34.1 understandthatlflheb If not.urze tlyhaveatenant,thatitlemy NEWRFSIDENIIALMECA. SQ.FT /I�s A�Crthoriwdagc eo a t of the requirements which a ¢met Vll 1Ano e e Occupancy. ,OJ I D e Y-. TO'!AG ISSUED BY�1ll OFFICE COPY