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20496 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY reBuildln Pro act Identification s �. PE}7MITN2 0 4 9 6 , Building Addss: D - OWA) D�31L, l/11NL wnere ,,1'_tyI 11hone. A CITY OF CUPERTINO-BUILDING DIVISION APPLICATION / PERMIT - e _` •' r C� BUILDING-ELECTMCAI PLUMBING-MECHANICAL CATEGORY - CONTROL#, Archited/Engineer. Lic.No: / ,Qty ELECTRICPERMIT FEE BUILDING PERMIT INFO Address: ✓ ,�-s PERMITIBSUANCE yA� ❑ ❑ El CONTRACTOR'S DECLARATION I hereby affimthat l sou licensed under provisions ofChapter9(mmmm APPOANCESRESIDENTIAL JOB DESCRIPTION ingwith Se On7000)OMAgon3oftheBuainemand ProfessiunsCcaihand my license Is In toll rcF d effect. PAN©9 License CWm�� Lk.#a Date—/ Contractor ARCHITECT`S ECLARATION 201-1000AMPS OAMPS %ZO I understand my place shall be used as public records. a OVER 1000 AMPS SQ.Fr.FLOOR AREA 8/SQ.FT. Fi ly Licensed Prafeasbrul - - SIGNS ELECTRICAL OWNER-BUILDER DECLARATION jn`Fd SPECGLCIRCNT/MISC V ' i., owing axon.IShaton 7031mptfromthed Profession.cess:Law fort he following reason.(Section 70315,Business and Professions Code:Any city or TEMP.METER OR POLE INST. rr4 muntywhich requires a permit to construct,alter,improve,demollsh,orrepalr g anystmd mprlortoiws ame,alsorequirestheappEvantforsuchp.r tto ppWEE DEVICES E5 �' file a signed statement that he M licensed pursuant to the provisions of the Contractor's License Law(Chapter9(mmmenring with Section 7000)of Divi- SWIMMING POOL ELECTRIC OJ Mon3 ofthe Businessand ProfesslonsCode)orthat he in exemptthereVALUATION - GS the basis for the alleged exemption. Any violation of Section 7031.5 by any UTLETSSWI'IDHFSFI%TURES ,00O applicant fora permit subjectatheapplicanttoa civil penalty ofnot morethan five hundred dollars 18500. ❑I,as owner of the property,or my employees with wages as their sok NEW RESIDENTfALELECTA SQFr. STORIES TYPE CONSTRUC HON compensation,will do the work and the structure is not Intended or offered for O sale(Sr. i ec.7044,Buness and Professions Code The Contractors License IA. r3 S does not apply to an owner of property who Wilda or improves thereon and OCC.CROUP RES.UNITS wbadnessuchworkhimselforthmugh hlsownemployees,provided thatsuch improvements are not Intended oroffered for sale.If,however,thebuilding or vemTOTA ' improentinsold wlthnoneyearofcompletlo theowner-bu0derw111 have ttcjZurden of proving that he did not build or improve for purpose of Bale.). QTY, LUMBING PERMIT FEE FLOOD ZONE APN u L as owner of the property,am exclusively contracting with licensed I ANCE contractors to construct the project(Sec.7074,Business end Professions Code: ' The Contractors License Law does not apply to an owner of property who - Wilds or improves thereon,and who contracts for such pto)eW with a -D N&VENT TER(EAI cgR(]aaoKs)licensed pursuant to the Contractors License Law. FEE SUMMARY LJ I am exempt under Sec. B&P C far thin on OTIC E F CON#. SANITARY Y N Owner - Date RECEIPT# t WORKMAN COMPENSATION DECLARATION ) SCHOOLTAX Y_ N_ - ❑I hereby affirm that I have a mmisonte of comm�t to self-Inwre,br a RECEIPT# cedificateofWorker Compema0onlrsurmmoramrtBledmpythereof(Sec. G .SY -1 C. OUTLETS PARK FEE Y N 3800,Lab C.) RECEIPT# Policy# " Cum ny GAS'ffi`'SYSTFM-OVER4 MAI BUILDING DIV]SION FEES artiCodified copy 6 herebyfurnished.the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE Codified copy Is tike with the city inspection division. . CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200F1. Date Recei f# (Thiaseclon need not be completed if the permit in forone hundred dollars (s100)orl..) ' WATER HEATER w/VENT/ELECTR - ENERGY FEE .,Y— N_ I certifythe m the performance of the work forwhich thin permit is issued, I shall not employ any person In any manner n as to become subject to the WATER SYSTEM/TREATING Worker Compensatlon Lawsof Califomia.Date PAID — 0 Z Applicant NEW RESIDENTIAL PLMB. SQ FT. Date Recei t# Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should bemme subject to the Worker Compamatlon provisions of the Labor TOTAL: W Code,youcovetforthMthcomplywithsuchprovislorsrrih6permltehallbe BUILDING FEE W > deemed revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE 'd O Ihereby atf(rmthat there is a construction lending agency forthe perform- ELECTRIC FEE' Z anre of the work for which this permit M issued(Sec.3097,Civ.C.) TOTAL: C.) 2 ]enders Nacre " PLUMBING FEE ' F Laeder.Address QTY. MECHANICAL PERMIT FEE LL MECHANICAL FEE O W Icertlfythatl Have read thinappliCatlon and statethatt fabs aboveInformationlam 11 incorrect lagmato Complywithallcityandcountyordinanm and Mate laws PERMIT ISSUANCE - FEES PAID: } N relating to building construction,and hereby authotlze representatives ofthis ci toenteru ontheal>o -m ntioned ro (wire edbn ALTER OR ADD TO MECH. ~ Z ryMe)agree to save,mdemNty an d keep ha Mess the City of Cpu pertino - Date Receipt# V against liabNties,judgments,erste and expenses which may in anyway a.me AIR HANDLING UNIT ITO 10,000 CFM) SUBTOTAL: 'ago Wt said City In consequence of the granting of this permit. - AIR HANDUNGUNIT(OVER 10,000CFM) CONSTRUCTION TAX Signature of Applicant/Contractor Date EXHAUST HOOD M/DUCT) CONSTRUCTION TAX PA ID: HAZA RDOUS MATERIALS DISCLOSURE ' Will the applicant orfuture building occupant store or hand In hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t# material as defined by the Cupertino Municipal Cade,Chapter 9AZ and the Health and Safety Codle��Se��ke,25532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: Will the applicant or(uNre building occupant use equipment or devious VENTILATION FAN(SINGLE RESID) ISW44WATE which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District? BORER-CAMP DHT`OR 100,003 STU) ❑Yen �Ii�1�I��.•�o ]have readthebazardousmatetlalsmquimmcntsunder Chapter6.95of BOILER-COMP(OVER 100,000 BTU) the California Health&Safety Code,Sections 75505,25533 and 25537.I p' understand that if building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH, SQ.FT. 9V resporui " rnotl the oc Pant of the requirements which must be met y Fri o issuan rt c otOmpanry. Ownero au o' dagent - Dae qss p TOTAL: OFFICE COPY