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20997 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY "unding Proed Identification PERMITNO. 0997 tlu0din Address: - �/�� 6 CITY OF CUPERTIN0.6UILDING DIVISION- en or. ante 6ZG 4SOR/,e 4;,:�ftq APPLICATION 1 PERMIT BUILDING-MFJCTRICALPUTMBINGMF LAICAL CATEGORY CONTROL X Architect/Faglaen Lk.No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: l LICENSED CONTRACTOR'S DECLARATION , my PERMITISSUANCE ❑ El ❑ therebythat aRceaedunder sofChap[er9(rommen APPLIANCSRESIDENTIAL JOB DSPTON IngwRhSection7D00)o(Div heauslnessandProlneloaCodeand icenseleIn(u to d effect. _ PANk]S Dan�ls C ntucto 201-1000 AMPS ARCHITECPS DECLARATION 9CO IundeutandmypkaehaRbeuwdupubherecoNe. OVERT AMPS 5Q.FT.FLOOR AREA S/°.Q.FT., (/ Licensed Frustrations] SIGNSEL 6 FLgy OWNER-BUILDER DECLARATION SPECIALCIRC T MLSC 1.., Iherebyaffirmthal lamnempt fromlhe Comranor's Liceae lawforthe 7p following reason.(Section 70715,Business and Professions Code:Any city or '^` r Oy TEM OR POLE INST. Py county which requires a permit to roatmet,site,Improve,demolish,or repair any structure prior to its Wuance,also requires the applicant for such permit to POWERD CES file a signed statement that he Is licensed pursuntto the pen son"of the �Dµ Contran°rb License Law Chapter 9(commencing with Section 7lXD)o(Dlvl- Y tie VALUATION Oa sion 3 ofthe Business and Profession Code)or that helsexemptthere(rom and POQLFlE C y 6 X the basis for the alleged exemption. Any violation of Section 70115 by any HFSFIXTUREBIt` l"'Y X�' applleant for a permit subjcda the applicant to a civil penalty of not more than five hundred dollars(S500). W R AL ELECTR ` SQ.FI. - E]1,as owner of the property,or my employees with wages as their sok SMRrr.S TYPE CONSTRUCTION compensation,willdothe work,and thestrunure It not Intended or offered for 11 uq psok(See 7004,Business and Pro(mebm Code:The Contnctoe LlceaeLaw ` don not apply to an owner of property who builds or imp=thereon,and `I OCC.GROUP RFS.UNITS whodme .s hworkhMulforthroughhaownemployen,providedthatwch Improvements an,not Intended oroffered forsale.If,howevepthebuilding or TOTAL: I :mprovementusoidw:thin oneyearofcwnpletb theowner-bullderwill have fla*rdeno(pmvingthalhedid not build orimprove for purpose ofuk.). QTY. PLUM TNG URMIT FEE LJ L as owner of the property,am exclusively contracting with licensed FLOOD TONE APN PERMIT NUANCE contractors to constructthe project(Sec.7066,Business and Professions Code: The Contractor's License Law does net apply to an owner of property who ALTER-DRAIN k VENT- Wilds or Improves thereon,and who contracts for such pkojens with a WATER(EA) - cc5actor(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY I am exempt under Sec B k P C for this reason BACKFLOW PROTECT.DEVICE DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N . Owner Date RECEIPT X WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y N I hereby affirm that I have a anl(Icate of cnsent to self-Insure,ora RECEIPT X cISA/rtf�Id/flwteofWorken'Compcmationlu mnmmaartifiedmpythem°f(Sec. GAS EA.SYRIM-1 INCA OUTLETS •PARK FILE Y N 3800,lab C.)��y/ 7 O� RECEIPT% Al Pollq•X L�7� Ca � GAS EA.SYSTEMAVER 4(EA) BUILDING DIVISION FEES Cert:le copy ls hed with the city GREASEANDUSMI,WASTE INTERCEPTOR PLANCHECK FEE Ce Ified copy ls(sled with the city inspection division. CERTIFICATEOFEXEMPTION FROMWORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWEWSANITARY-SIURM EA.200FT. Date Reeel t# (hisaedkn need cad becompleted:f the permit ls foroa hundred dollars ($100)ortmj WATER HEATER W/VENT/ELECTR ENERGY FEE Y N lartifythatintheperfomunce ofthework f which this permit b timed, I shall nm emylpn an person In any er as to roi a ' o the WA•I,CR 5Y51,CM/.I.REA.I.INC Workeri Co t las o - PAID O Z Appllant / M - NEW RESIDENTIAL ELMS. SQ.FT. Date Re:ei t# Z O NOTId become s I to after maW h ertnicateof Exempt the should become subject to the Workers'Compensation provlsloa of the GWr TOTAL: N Code,you must forthwith comply with such provisions or this permit hall be N 11 CC CC W 7 dMmcd revoked. BUILDI r LU c CONSTRUCTION LENDING AGENCY SEISMIC FEE l I hereby a(firmthat there Is construction lend Ing agency for the perform- ELECTRIC FEE SO M Z onceof the work for which this permit b,lasued(Sm 3097,Civ.C.) TOTAL: 00 Lender'.Name PLUMBING FEE H Lender's'Address QTY. MECHANICAL PERMIT FEE LL MECHANICAL FEE OW I cenlfythatl havereadthis applicat:°nand statethactheabowinfomutlon d is correct,I agree to comply with all city and county ordinances and nate laws PERMIT ISSUANCE FEES PAID: } N relating to building construction,and hereby authorize representatives of this cat to entero n the above-mentioned for W loci s ALTER OR ADD TO MECH. Z y upon kee In rootless the p"rpO9e Date Recei t# (Ne)agree to ave,indemnify and tin harMen the City o(Cupertlne V ago IabNt jrdgmenta,mrtsand ex i:gwhich yin anywayacerue AIR HANDLING UNIT CTO 10,000 CFM) SUBTOTAL: a old Ci itn-covn(elejiu-e(-/o/e//vo�/the satin °(this permit. r A0-41-90 AIR HANDLING UNIT(OVER l0,000CFM) CONSTRUCTION TAX Sigatom.f AppRcent/Contractor Date EXHAUST HOOD M/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will theapplicanl or f tum building ocutpant store or handle hazardous HEATING UNIT(TO 700,000 BM Date Recei t# material as defined by the upertino Municipal Code,Chapter 9.12,and the Halthand SafetyC ctio,25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: YeaNo' W:Illheapplic uo future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSpI{LI;I�DATE hich emit hazardous air contaminants as defined by the Bay Area Air Q[/"N+@�J Quality Management D t 7 BOILER-COMP OHP OR 100,000 BTLU 4 Yee Q �+ • havercadthehaza ousmalenaisrequirementsunder Chapter 6.95of BOILER-COMP(OVM100,000BTU) Q T 41990 the Cailfomla Health Safety Code,Sections 25505,75533 and 25534.1 understandthatlfthe uildlog doesnot currently have a tenant,that it E my NEW RESIDENTIAL MECH. SQFT respoa Ilitytondilytheoccupantofthe Iremenlawhlch muslW rret t T}M4/p prior n daCertifi ( pa eror auC ��Datte ISSl1ED BY:V lJ TOTAL: 1 OFFICE COPY