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19945 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Prom IdemmcationPkizo �T�f T EeF� t PRLwTNO. Building Address: �F„ I �1_ 19945 1011-5 N. ©LM # 20748 2�/6 P> vers ame: Ilh..tf APPLICAIIONSUBMHIALDAIL w�o �glp win. 255-5696 CITY OF CUPERTINO-BUILDING DIVISION Contractors Name: ` Lic.Na: APPLICATION / PERMITAft, WViq'NMt> BUILDINGQ.FLTRICAL-PLUMBING-MECHAMCAL CATEGORY CONTROL pS-7IC(MW q���,Iter�t�,�Fsgl .may e A� Lle.Na: a UAN:( A6 L ,9,,, QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO Address: PERhITISSUANCE ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION I hereby aoA70thatlam0ce3ofte provisions of Chapter 9(mmmrnc AIPPLIA ESREADENTIAL JOB DESCRIPTION It...h i.f.1170W)ofd effect. ofthe Buslneuand ProfnUonaCode,and my license b in full forty end d(ect. PANES Licenx Clam Co r (�� Date Contractor ARCHITECTS DECLARATION 1000 OZ I understand my plans dull be used m publicrecords SQ.FI.FLOOR AREA S/SQ.Ff. O (Cj Licenxd Professional SIG LEC7R1 AJ 6 OWNER-BUILDER DECLARATION TALC / TSC I herebyaffirmthal l am exempt from the Contractor'sI I--U -the }0'9 � folbwingreaaon.(SMIon7m]S,Bu,InemandPm(ealonaCode:AnXZn p, ORI'OLEI countywhkh requlresa permktomnsttutt,alter,lmpmve,demolish, NVIN F�[ 'ara anystruttureprlortoitslssuance,alsorequlm theappbantforsuchpWER DEVICES a w V file a,Ipcd statement that he Is licensed pursuant to the provisions Contractor's License Law(Chapter 9(commencing with Section 7000) NC POOL E.E E,30 sion3ofthc Business and Prefeselons Code)orilue heb exempt therefVALUATION Sn 3 the basis for the alleged exemption. Any violation of Section 7071.5 E7S �/ ,^ /` O �« appBantfor a permit subjects the applicant loa dull pevltydna mV V F f'vt�e lundred dollars(S500). EWRFSID L MRI TYPECONSTRUC'HON �n c76XT'I,as owner of the property,or my employees with wages as th pensatlon,wflldolhe work and thestrocture Is not Intended or offered for ti p sale(Sec.7044,Business and Profemlans Cade:The Contractors License Law r $$ does not apply to an owner of property who builds or improves thereon,and OCC.GROUT' RFS.UND'S whodoessuchworkhlon Iorthrough hisawnemployera,provided that such improvements are not Intended oroffemd forsale.IL however,thebuilding or T Improvement issold withmoneyearofcumplction,theowner-bullderwill have to -denof proving that he did notbuddorimproveforpurposcofsale.). QTY. PLUMBING FEE FLOOD ZONE APN IJ L as owner of the property,am exclusively contracting with Licenxd PERMIT ISSUANCE contractors to construct the Project(Sec.7014,Business and Professions Code: The Contractor',License Law does not apply to an owner of property who ALTER-DRAIN k VEM-WATER(EA)Wilds or Improves thereon,and who contracts for such pnojec s with a FEE SUMMARY on courts) pursuant to the Contractors License Law, BACK FLOW PROTECT.DEVICE 15 1 am exempt under Sec. B A P C for this reason OUTSIDE FEES DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N Owner Date RECEIPT# ' WORKMAN COMPENSATION DECLARATION FIX.IlIRFS PER TRAP SCHOOLTAX Y_ N_ 171 hereby a(firtn that I have a certificate of consent to self-mare,ora RECEIPT# certificate ofWorkeri Compensation Imurance ora unified copy thereof(See. GAS EA.SYSTEM-1 INCA OUTLETS PARK FIE Y_ N_ 3800.Lab C.) RECEIPT# Policy# GAS EA.SYS E1,4-OVER 4(EA) BUILDING D I VIS ION FE ES Com any CertlRed copy b hereby furnished. GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE q Certified copy b flied with the city inspection division. ) ��C•D CERTIFICATE OF UEM PTION FROM WOR KERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 7(pFF Date Rc i t# (fhb seniors need net W complded If the perrmt b for one hundred dollars ($100),ohns.) WATER HFATFdt W/VENT/E.ECTR ENERGY FEE Y_ N_ I cortify that N mce the perfounof the work forwhlch this permit b Issued, I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING WorkersCompensation Laws of Callfomla.Date PAID OZ Applicant NEW RFS DENTALPLMB. SQFT. Date Remi t# Z O NOTICE TO APPLICANT:If,after making this Cenlflate of Exemption,you should become subject to the Workers'Comns peation provedmes of the Labor TOTAL: CCN Code,you most forthwith comply with such provl,lons orthis permit shall be BUILDING FEE 0 W ] dren<d revoked. d CONSTRUCTION Is a ON LENDING AGENCY SEISMIC FEE I hereby for w lherebaconstro intend agency for the peAomr TOTAL: ELECTRIC FEE � Z anceofthe workforwhichthb perMt bLuued(Sec.3M.Cie.C.) PLUMBING FEE LL O Lender's Name LL F I<ndors"ddren QTY. MECHANICAL PERMIT FEE MECHANICAL FEE 0U Iced.Iagree to comply is with allcitlanand dcunty ordinances a In formation O W relating to Iagrn to complyweh andthemb auhortu rnancesand state laws PERMIT ISSUANCE FEES PAID: D• reytoenobupongconstruction, ,ntto 1propetyorlureotam tativics purposes. Z cityWenteree to the aned property for WpMbn purposes. ALIIIt OR ADDTO MECH. (We)agree to widg indemnify and keep harmless the City of ayaccero Date ReOTAL V ait gaimtliabilities,jrdgment,,mrte and expenses which may In any wayaccrue AIR HANDLING IIMT(I'010,00(1 CFM) SUBTOTAL: against said City in consequenm of the gra ruing of this permit. AIR HANDLING[JMT(OVER l0,000CIiM) CONSTRUCTION TAX Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle haurdoos HEATING UNIT(TO ID0,(00 BTU) Date Recel t# material as defined by the Cupertino Municipal Code,Chapter 9.17,and the Health and Safety Code Section 7553I(a)7 HEATING UNIT(OVER 1OQ000 BTU) TOTAL: Fly. u No Will the applicant or future Wilding occupant use equipment ordevias VENTILATION FAN(SINGLE RF_SID) ISSUANCE DATE which emit haeurdous air romaminantsas defined by the Bay Arca At, ,1 A#YC Quality Management D❑ivrim4 BOILER-COMP DHPOR 100,000 BTU) ,Iy111 - 15 4 Yea N No � -1E�Vt1f+ have rcadf,alth a tedab i..255ntsunderChapte4. 1 of BOILER-COMP(OVE2100,000 BTU) /1P � 1990 the a llanmia Health bSafety Code,Sections 5505,v..t and 75574. 1 1111 understand tlulitlhe Wilding docs raft the encs tenant,lost it met NEW RESIDENTIAL MECH. 5'Q.Fp. respo ibilityt notify a ant of the rcqulremenlswhich most be met p�*I c off IIIc lOmpancy. `7J (f CUB Ing a ru,cxr atWhrrhnd age , Date ISSUI!D BY: TOTAL: OFFICE COPY