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20587APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY Building Proect Identification Building Add res.: ., cM L 3 A v czC0 PKW PERMITNO. 20587, ra ams:. ,1 - one: -TANAGI•,'&Qrn iE2S CITY OF CUPERTIN0.BUILDING DIVISION_qpl APPLICATION / PERMIT BUILDINGELECnUCAL-PLUMBINGMECHAMCAL SUBMITTALLICA TION ' © l l0 - Q ck.NP : 1 �z • 3 / 1 CATEGORY CONTROL 46 19 IT BUILDING PERMIT INFO '1 Architect/Englneen Llc. No: QrY ELECTRIC PERMIT FEE N —PERMITISSUANCE CIT ❑ ElLICENS ISG El I a CONTRACTOR'S DECLARATION [hereby affirmtFat lam lkenseduMhl under prwons o(Chapter9 (mnvnenc- ingwithSectlon7000)ofDIW°ion3o(1he�Bjusliiescand[+r/pfeaelonsCode,and my licenseisin fuB deflect. L 7 / 1 License Cla Lk. N r7 L Date. Contractor RCHITECP D ION" luraderetandmyplaw+hallbeuwdmpubllcreconls. Licensed Profesaideal OWNER -BUILDER DECLARATION I hereby afirmthat I am exempt from the Contractor''+License wforthe folbwing reason. (Section 7811.5, Bu+loess and Professl°na . My city or county, which requires a permit to construct, alter,lmpmve, d Ihh,oreepair anystmu mpkortoibh ance,ahnrequiresthe pit forauchpermitw file a signed statement that MIs licensed pursuant to a provisions of the ContractarbLicenseLaw(Chapter 9(commencing 5.dkm7000)of by DiA- skm3 oflhe Buguudand Profe°°Ions Code)mth eisiumn therefromand .the basis for the alleged exemption. Any viol on of Section act ers me any pe app hundredaollars subjectethe applicant aaivll penalty of not nnrethan (ave hundred melees ($500). ❑I,asowner l theproperty, d m mpum is with wages r their sole tim-med for compensation, wBld°theworrofk. et ode:Th Contendeot intendede.rs us sae (Sec. appy t apply to ainow and Prof y w o builds Contractors Llceeue Law Liame Law whoddoes ossucht apply toanownerofp rtywho buimporimproovidedves 'hereoryand whodoeesuchweluftintelf or roughhhowale.It owevrthebrthatsuer Improvement issold ith eyearofcomplein ioe the er-q Uder illi ve imprurdenofhsoing, edidn net orim rove fo purp se ofulha). tlLrdenofpmving ropers, a bund orlmpmveforing wieofcense u L os owner of a property, Se exclusively contracting essi sCodd contractors to m et the project (Sec, appy Business and of probns Code: Wil TheCoor I scene¢ law mesa oat apply to an owner of property who Wilds m 1 roves thereon, and who contracts for such ptojern with a co,I t�acto erupt unpo der ntm the Contraet�r�Lk&P Law, men U I exempt under Sec B & P C for this reawn APPLIANCES-RESIDENTIAL pgN19S ' DESCRIPTIO 201-I000AMPS- OVER1(IOf/AMPS SQ. FT. FLOOR AREA 7$/SQ - - SIGNS ELECTRICAL SP[CVeLCIRCIRT/M t TEMP. METER OR ['OLE INST. WFR DEVICE ' S ` NG POOL VALUATION VALUATION OUTTIFTSSWITC NEW RE.SID IR t 1 STORIES TYPE CONSIRUCTTON 000.GROUP' - RES.ONTTS OTA QTY. PLUMBING PERMIT FEE PERMITISSUANCE - ALTER -DRAIN & VENT- WATER (EA) pf-OODZANE� APN . RACY FLOW PROTECT. DEVICE FEE SUMMARY nor Date DRAINS FLOOR, ROOF, AREA, GOND. FIRTURES PER TRAP SANITARY Y_ N_ RECEIPT # WORKMAN COMPENSATION DECLARATION ❑i hereby affirm that 1 have a certiflrate of consent d °pytheure, ora 380 Litte olWorken'Compewtlonlnsurance oracertllled copythereof(Sec. Poll;;# CJ �G Poliryp r �R lQ D DI LIG SCHOOL TAX Y N RECEIPT N GAS-EASYSTEMI INCAOIITLETS PARK FEE V N Co���m Celt A--- ary—CA&EA. I ICemfied copy is hereby furnished. Ceki(led copy h filed with the city Inspection divhlon. CS. CERTIFICATE OF EXEMPTION FR ORKERS' COMPENSATION I NCE (Thissectbn need net"ccomplMed permit h for one hundred dollare ($100)orf that Icertlfythat fin peke of the for which the permit is hewed, I shall not employ any pe n In any manner ro u to become subject to the Workers' Compenes" we of Califomta. Date Applicant SYSTEM-OVER4(EA) DINGRECEPT# BUILDING DIVISION FEES GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE PAID /•° �d _ Date Recei t# '?,is E GREASE TRAP SE'WER-F.ANITARY-STORM EA. 200FT. WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_- G //��(L� PAJTY'�" D s� r Date Recei t# $�.0 WATER SYSTEM/TREATING NOTICE TO ICANT:IL after making tMs CerH(Inte of Exemption, you should be subject to the Workera' Compensation provisions of the Labor Code, moat forthwith comply with such provhionsorlhh permltehali be d d revokd. e CONSTRUCTION LENDING AGENCY IherebyafRrm that there is a construction lending agency for the perform anceof the work forwhkh this permit h hewed (Sec. 3097, Civ. C.) Lender'+Name Lender'+Address I denuythatl have readthh applicalionand statelhenthe above Information is comct. Iagree to comply with all city and county ordinances and nate laws relating to building construction, and herebyauthod mpresentativesofthh city to enterupon the above-mentioned property for inspection purposes. (We) agree to save,m eNly an d keep harmlm ethe City of Cupertino agaimt iabihtles, ju rats, eost. and expenses which may in enywayacaue dCity In n once of the granting of this permit I a o ApplJ&mt/Contractor to ' HAZARDOUS MATERIALS DISCLOSURE Wllltheapplicantmfuture building occupant store or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.14, and the Health and Safety Code. 25532(a)T ❑ Yea No Will the applicant orfuture building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air It Iity Management etrlct7 ff 44 Yca o Hese owe mode, le requirements 5,2553 and 25534.1 of California 1 the understand Health &SafetyCode, oteurentlyh have undervtand that lithe building does not cvmnliy have atenan5 that lHs my tenant, that responsibility to notify the occupant ofthhe requirements which ust be met por,,t�his race of C,,mflc in foccv an Cwki Lvh:ncentw 4 ✓ �2. Cwger authorized agent �� -� DSS D NEW RESIDENTIAL PLMB. SOFT. TOTAL: BUIL ' G - TOTAL: SEISMIC FEE ELECTRIC FEE QTY. MECHANICAL PERMIT FEE PLUMBING FEE PERMITISSUANCE ALTERORADDTOMECH. MECHANICAL FEE FEES PAID: Dale Receipt# - AIR HANDLING UNIT (To 10,000 CFM) -SUBTOTAL: AIR HANDLING UNIT (OVER 1o,floocFnr) CONSTRUCTION TAX ExHAusTHooD(W/DUCT CONSTRUCTION TAX PAID: - HEATING UMT(TO 100,000 BTU) - - Date 'Recti f# HEATING UNIT (OVER 100,000 BTU) TOTAL: I, Ilk VENTILATION FAN (SINGLE RESID) J$SJJB3ITSIRBq'J'E iNp::id�"'���J 1 1, r le - .City of Cupp p o ISSUED BY: BOILER -COMP OHP OR 100,000 BTU) BOILER-COMP(OVER 1(q,0(D RTU) NEW RESIDENTIAL MECH. SQ.F'r. TOTAL: OFFICE COPY a