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20247 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY Building Project Identification I Building Address: «6.5z $?_LoGr_ _FAP-� <---C PUI TNO. 20247 sera Iii. Phone: It, LL CITY OF CUPERTIN6BUILDING DIVISION. APPLICATION / PERMIT IL ^_ A 5 ^�6 caRtradar'e N,me: Lia. Na: BITILDINGELECTRICALPLUMBING-MECHAMCAL CATEGORY CONIROLN A Ited/En®ear. Lie. N. QTY'" ?..ELECTRIC PERMIT j' .;-:FEE ' BUILDING PERMIT/NFO, Address: '7 PEU.UTISSUANCE - E] O El CONTRACTOR'S DECLARATION APPLIANCES -RESIDENTIAL Therebyaffirm that Icess licmaed under provisions of Chapter9(comment, Ingwith5edion70M)ofDlvbion3ofthe BualnesaandProfeuions Code, and my licences is ifull soros and died. c License Clae m Llff if JOBDESCRUMON PANES Date Contractor �-s ARCHITECTS DECLARATION I undentann pry Flamahall by Necd/p pu Bc records �Ji f6F 201-1000 AMPS OVERIWOAMPS SQ. FT. FLOOR AREA S/SQ. Ff. SIGNS ELECTRICAL /a' Licensed Proftonal OWNER -BUILDER DECLARATION I henebyaffurrmthat I am exempt fromthe Contractors Limnee Law forthe following reason.(ScMon7(31-5, Business and Professions Code: My city or muntywhieh nequcresa permit tomrutruct, alter, Improve, demolleh,orrepalr anystrodure prior to its Issuance, -line requires thesppBant for such permit to foe a signed statement that he is licensed pursuant to the provisions of the Contrsdoes License Law (Chapter 9(commanding with Section 7000) of Divl- don 3 ofthe Business and Profeed ru Code) or that he iseaempt therefromand the Iasis for the alleged exemption. My violation of Section 7031.5^ by any applicant fora pemdt subjects the applicant too civil penalty of not mare than five hundred dollars (SSOB). ❑ I, as owner of the property, or my employees with wages as their sok mmpeasation,will clothe work, andthegrocture, is not Intended or offered for sale (Sec 70K Sualness and Professions, Code: The Contexctue. License Law does Rot apply to M owner of property who builds or improve therron,and who doessuchwarkhlmvelforthmugh Msownempluyere provided thatach Improvements arc not Intended oroffered (waste. If, however, thebullding or improvementlssoldwithin oneyearofcompletim, theowner-builderwBl have th�r,�urden of proving that he ddidno[bu0d or lmpmve (or purpose o(ule.). u L as Owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec44, 70Business and profession, Code: The Contractor's License Law don not apply to an owner of property who builds Or Improves thereon, and who contracts ct for such p4ajes with a cgR(faCar(al Bcenxd pursuant to the Contraa ar's License Law. LII am exempt under Sen B k P C for this reason SPECIAL CIRCUIT/M15C 7pMP. METER OR POLE INST. POWER DEVICES SWIMMING POOL ELECTRIC OUTLETSSW[TCHFSFIXTURFS VALUATION aD OOQ-C$ ..+ NEW RESIDENTIAL ELECTR _SQFT. STORIES TYPE CONSTRUCTION TOTAL: jS 1,T ' QTY -,- -PI:UMBING PERMFFx t i' ;SrFE$G PERMIT ISSUANCE ALTER -DRAIN& VENT- WA,�i(EAI OCC. CROUP RFS. UNITS ).TpOD 7pNE APN BACK FLOW PROTECT. DEVICE a 3' "`-'y'-:.;FEE SUMMARY. `- `-- ,.' Owner Date WORKMAN COMPENSATION DECLARATION ❑I hereby affirm that I have a certlfiate of consent to sel4Inare, w DRAINS FLOOR ROOF, AREA, COND. SANITARY Y_ N_ RECEIPT s FIXTURES. PER TRAP SCHOOL TAX Y N a certUlate.(Workers' Compensation L...carscertified copy tre heof(Sec. 3800,IAb C.) Policy Y RECERrTa GAS EA. SYSTEM -1 INC.4 OUTLETS PARKFEE Y N RECEIPT a Co any EC21fiified copy ishereby th the cid. ❑CertJed copy is filed with the city inspection division. GAS FA. SYSTEM -OVER 4 (EA) GREASE/INDUSTRL WASTE INTERCEPTOR BUILDING DIVISIONFEE$ PLANCHECK FEE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (TMsseneed not be completed lithe permit is(carcase hundred dollars (St0()orless')s.) Mat In the a l.e 1.c issued, Ill PAID Date Regi t# 2� `� GRFASETRAP SEWER -SANITARY -STORM EA 2DBIFT WATER HEATER W/VENT/ELECTA ENERGY FEE Y N Am Person, i I shall RO employ any peam In any rtunner a u to become abject /o the any manner an 0 to suby Applicant Lawn of California. Date NOTICE NOTICE 70 APPLICANT-. R, wryer making this CertBkale of Exemption, you should become subject to the Workers' Compensation provisions of the Labor Cade, you mat forthwith mmply with such pmvisiam orthis permit shall be deemed revoked. PAID Date Recei t# WATER SYSTEM/TRFA'RNG NEW RESIDENTIAL PLMB.__SQ.FT. TOTAL: IN TOTAL: CONSTRUCTION LENDING AGENCY I hereby affirm that then is a coaatmdlon lending agency for the performELECTRIC Ana of the work for which this permit is Issued (Sec. 3097, Civ. C.) SEISMIC FEE FEE finder's Name Landers Address IRMITx.,;,, certifythat I have readthisappBoh-n.M gatetbatthe above Inf..tion is mired.] agree to comply with all city and county ordinances and gate laws relating to building mretadion, and hereby,uthome, representatives of this city to enter upon the abovsmentioned property for inspection purposes. (We) agree to ave, Indemnify an d keep harmles the City of Cupertino againgliabWties,judgments,mgsand expensewhich rayl. anywayaccrue ZSUBTOTAL• against said City in consequence of the granting of this permit. QTY.„, MECHANICAL.PE PERMIT ISSUANCE ALTERORADDTOMECH. AIR HANDLING UNIT If010,” CFM) PLUMBING FEE MECHANICAL FEE FEES PAID: Date Receipt# AIR HANDLING UNIT (OVER 10,000 CFM) CONSTRUCTION TAX Sigamre Of AppRcam/Contractor Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle harzrdous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the He❑altYnd Safety Cade, SeNloon 75532(x)7 EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HEATING UNIT (TO 100,00 BTU) Date Recei t# HEATING UNIT (OVER 100,000 BTU) TOTAL: Will the applicant or future building occupant use equipment or devices which eM1 harardom air conlaMnams as dellned by the Bay Area Air Quality Management D❑iissttjrict? 4haweread the hazardausmateriaisrequlmmentsunderGhapte, 6.95 of the Califwnla Health A Safety Code, Sections 25505, 25533 and 25534. 1 understand that if the building does not currently have a tenant, that it is my rnpora I tonctlfy the occupant of the requirements which at be met VENTILATION FAN (SINGLE REBID) &4WRNCE DATE -- i ^;iy p{ PIf�eT''jplT. - -- BOILER -COMP OHPOR 100,000 BTU) BOILER -COMP (OVER 100,000 BTU) NEW RESIDENTIAL MEC -I. SQ.F7. prior o fastainice of a Certl(Icate (Diss, ISSUEDBY��O — .1 a : Breda est V Date TOTAL: OFFICE COPY