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22880 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identificationnae - ^ ., - PERMIT NO. Building Add : /y_ mu —V^N .228-80 C) 24EI'ZS56 z ne: APPLICATION SUBMITTAL err' S CITY OF CUPERTINQBUILDING DIVISION Co -c`or' me• LIc.N. APPLICATION I PERMIT • BUILDING-MECTWCAAML BINC-MECH MCAL CATEGORY - - ' COMROL is ArcluBcOingireer. Lie No: QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO Address: PERMITISUANCE [:1 p LICENSED CONTRACTOR'S DECLARATION I hereby affirm that lam llceneed under provisions ofChapterg(comment, APPLIANCESRESIDENIIAL ]OB DESCRB'TION ingwith Sedion7DM)of Dlvlcion3ofthe BuslnessandPmfesslansCode,and my ` license is in fitores defied. PANELS C Lim Ches aeCcomento 001L'I-[ ARCHITECTS DECLARATION 101-I0W AMPS pQ+9OZ l understand my plane shall be used as public records. OVER1000AMPS SQ.Fr.FLOOR AREA S/SQ.Fr. E� Licensed Professional SIGNS ELECTRICAL 'L�E D I N' G< OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC UTE R 1herebyafRrmmmvj <hatIaexeptfromtheContractor'sLlceneeLawforthe p qqqq following reason.(SecHon 7031.5.Business and Professions Code:My city or TEMP.METER OR POLE INST. F county which requires a permit to construct,alter,Imp rove,demolish,or repair 7 any stmeture prior to Its issuance,also requires,the applicant for such permit to POIypR DENCEq �. Rle a signed statement that he is;licensed pursuant to the provisions of the Ou,y Contracto/a License Law(Chapter9(rommencing with Section 7010)of Dlvl- SWIMMING POOL ELECTRIC• �� LU 30 J7 sion3 of the Business and Pedralma,Code)or that he In exempttherefromand I the baels for the alleged exemption. Any violation of Section 70H.5 by any OUTLETSSWDCHFSFD(T URES 0 applicant fora permit subjects the applicant to a civil penalty of not nnrcthan 6 (iv ffundrcd dol hesEESM. NEW RESIDENTIAL ELECTR SQFf. SIDRIES TYPECONSIRLUJION I,as owner of the property,or my employees with wages as their sok compensatim,wBldothe work andthestmcture is not Intended or offered for Osilo/Sac 7094,Business and Professions Code:The Contractor's Llceme Law does not apply to an owner of property who builds or Improves thereory and OCC.GROUP RES.UNITS who does such work himself or through his own employees,provided that such Improvements are not Intended or offered for sale.If,however,the building or TOTAL: improvement is said within one yearofcomple0ory the owner-builderw111 have t�Ckurden ofproving that he did not build or bnprove for purpose o(sak.). QTY. PLUMBING PERMIT FEE FLOOD TONE - APN LJ L as owner of the property,am exclusively contracting with licensed PFRMFr L%UANCE contractor to construct the project(Sec.7044 Business and Professions Code: - .. The Contractor's License Law does net apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) bunds or Improves thereon, and who contracts for such p(ojects with a FEE SUMMARY 9)licensed pursuant in the Contractors License Law. BACK FLOW PROTECT.DEVICE L�I am exempt under Sec B &P C for this reason OUTSIDE FLES DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y_.N_ • Owner Date - I RECEIPT_ NN WORKMAN COMPENSATION DECLARATION FD(TURES-PER TRAP SQi00l TAX Y N ❑1 hereby affirm that I have• Insurance of consent to copy ythereo or RFLEI NN certificate orkers'Compensatlm Insurance ora certi(kd mpythenrof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE '� Y N 3800,Lb C.I ' RPN PS tl - GAEA.SYSI7M-0OVER BUILDINGING DIVISION FEES C.mj1 n�TZMlfled copy is hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE Certified copy is filed with the city Inspection division. CERTIFICATE OF EMITION FROM WORKERS' GREASETRAP D( PAID COMPENSATION INSURANCE SEWEILSANFFARY-STORM EA IO(IFF. Rate RCCYI tR . (This secilon need not be,completed lithe permit Wine one hundred dollar (910()orlem.) - ENER N N Ica"Bythat N the performance of the work forwhich this permit is Issued, WATER HEATER W/VENT/E.ELTR — I shall not employ any person In any manner so as to become suhim to the WATER SYSTUA/TREATING P t Q3T Worker'Compensation Laws of California.Date w O Z NEW Date Remi tM Z NOTICE TO APPLICANT:If,after nuking this Certificate of Exemption,you h'W RESIDENTIAL PLMB._SQFf. 0 should become subject to the Workers'Compensation provisions of the Labor NOTAL:us should mastfathMthmmplywithmchpmvls morthls perrNtshallbe L j deemed revoked. W CONSTRUCTION LENDING AGENCY SEISMIC FEE ' a C I herebyafOrenthat there is a comtruction lendingagency forthe perform - TOTAL: ELECTRICFEE- M Z ance ofthe workforwhichthls permit is lssued(Sec.3097,CIv.C.) PLUMBING FEE 52 Lenders No LL H Larder's Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE ' U 1 Aifythatl havereadthlsappliatlonand statethat theabove Information FEE$PAID: O W m lsrrert,I agreeto comply with all cityand counaws tyordirusees and state lPERMITISSUANCE r 1 relating tobuilding mvtmetion,and hembyauthorlssropmocatativesofthis ' N ALTER OR ADD TO MECH. Z city to enter upon the above-mentlonnd property for inspection purposes. Date Re ci t# V (We)agree to save,Indemnify an d keep harmless the City of Cupertino agalnst liabilities,ftdgments,coatsandexpenses which may In anywayacvuo AIR HANDLING UNIT(TOIO,OW CFM) SUBTOTAL: a aI tsald Cl In con mol ofihe antingoclaspermit' - - CONSTRUCTION TAX AIR HANDLING UNIT(OVER 10,000 CFM) Sinatum of pplimnt/ omranar Dat IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS1 SURE Will the applicant or future building oavpa mreor handle hazardous HEATING UMT CTO 100,000 BTU) Date ReCei tilt materhi as defined by the Cupertino Municipal Code,Chapter 9.IZ and the Health and Safety Code Section 15531(1)7 HEATING UNIT(OVER 1W,000 BTU) TOTAL: ❑ Yrs ,I+�—.I No VENHILATION FAN RESID) ISSUANCE DATE W illmh applicant or(core building occupant use theequipmcraArea or devices whicheManagement District? unto as dented by the Bay Arca Alr 'YO�t Quality Management District? BOILER-COMP OHP OR 100,000 BTU) "assla 4Ya n No haiforead the niaHeath&SafetyCode,Secequiremenb5533anChapter G95of BOLER-COMPOVERIW,OWBTU) the California Health&Safety Code, of currently 25505,25533 a t and 15534. I +✓/ understand that if the building does not currently have atenanL that ltlsmy NEW RESIDENTIAL MECFT.- SQ.FT. responsibility to notify the occupant of the rcqulrcmenb which mo at be mat p prior to issuance of a Certificate ofOttvpanry. r'. - 6t V^u Q8:t1fl* Owner or authorized agent - - Date TOTAL: ISSUED BY: OFFICE COPY