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21254 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Prom Identification PERMITNO. % Address: c4adl T� 1 21254 worn came: - b'7G�+'MdY�d Nzhclr)4ejo-• aY'W-S1 CITY OF CUPERTINO-BUILDING DIVISION Contractor's Name: Le.No: APPLICATION I PERMIT BUILDINGELECTRICAL-PLUMBINGMECHAMCAL CATEGORY CONTROL M Architect/Englmer. - Lac.No: QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO Address: PERM9TISSUANCE LICENSED CONTRACTOR'S pr DECLARATION [heh Sodto 70lhatl iv licensedunderBusirovIswnaofessioer9(mmmene APPLIANCES-RESIDENTIAL JOB DESCRIPTION Incense Is ect un fore'and Bumneaeand Pro(esmomCode,and Ltome Is In wB torte and d(ect. PANF]S D.teClaes Llce t Date Conlriitor ARCHITECTS DECLARATION 201-IODOAMN n // �+!aO Zp (understand my pbwshzBbe used as public records OVERI000AMPS SQ.FI.FLOOR AREA $/SQ.FT. qq E dct, Licensed Professional SIGNS ELECTRI(A s <6�a OWNER-BUILDER DECLARATION t RpECIALCIRCUTT/ML4CI !. so.,Yd owing reason. (Se a on 7ezemp(mms a Contractorssimmer low fou the _• rO Z following reason.(Section 70.11.5,Business and r, fpmons Code:Any city it P.METER O LE(NST! F .wystm khregrtaits me,aco requimatheapli=tfmwch,er tto any structure pater tents thausmgaloonscd pursuant to he rewislhpemdte yyr' � 's +1 (Ilea actor's statement that he Is licensed pursuant to the provimona of the Pr� �lD[MCNS ) u•(I.. Mon 3 ofthsLicenseusbes Lew(Chapter 9(commencing with Sectionherefof Divi- SVI1A1nf1 FOOLEL a C mon3oftheBwinea and ProfembauCode)orthal hebeumptthere(romand - F'I' t VALUATION ]] the bash tar the alleged exemption. Any violation of Section 7BlIS byany aa.j��P� [� papplicant for a permit subjects the applicant to a civil penalty of nor morethan O TOHES tw Q©G Ove dred dollars(g.SWj. gam' a owner of the roe W RESIDENTIAL RLFL SQ.Ff. SI'OR[FS TYPECONSTRUCTION p p rty,or my employees with wage as there sole mpensaHon,B.MrswUldlheworranathes Code:rche is Corux mendea License Lawd for -� p le(Seepply to anowandfpmpety Code:The or improve, themor,Law does ser apply toanowmrorpropertywhohalideorimprovesthereon,ane OCC.GROUP RFS.UNITS TILL whodoes euchworkhlmvel(orthrwgh hlsownemployeea,plwWed that such Improvements arc not intended ororfered forsale.If,however,thebuikling or TOTAL: am Improvement Iswld wlthinoneyearorcomplmion,the owner bullderwlll have t adenorproving that he did rot build or improve forpurpose ofsals.). QTY, PLUMBING PERMIT FEE ELOOD ZONE APN Lj I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE 1 contractors to construct the project(Sec 7004,Business and Professsom Code: l� _ The Contrs t.e.License Law does not apply to an owner of property who mA .DRAIN&VENT•WATER(FA) Weon ilda or Improves thereon,and who contractscontractsck for soIn jems with a FEE SUMMARY actor(a) or' licensed pursuant to the Contracts License Law. BAIX WPROT[CT.DEVICE 5B.t;I amexemptunder Sec B&P C for this reason DRAINS R ROOF,AREA,CONTI. SANITARY Y N r® Owner Date RECEIPT M WORKMAN COMPENSATION DECLARATION ty SCHOOL TAX Y N of hereby'(flan that I have a sand iate or consent to aeBd wire,ora 2 r` TRAP -1N� RECEIPT Y otniflateorWerkera'Compiosmian Insurance ora certified copy the. (See. GAS F.A. - INC.d OUTLETS PARK FEE Y N MOO,Lab Cd RF7CEB'C N Polley M GAS EA.SYSTEM-O R 4(EA)Com any -- I BUILDING DIVISION FEES -ertlfted copy Is hereby famished. GREASE/INDUSIRL WA I EPTOR PLANCHECK FEE Certlfled copy b filed with the city)napecturt division. CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWER-SANITARY SIO FT Date Recd t# (Thissectionneednot Mcompleted ifthepermiti foromhundred dollen ($100)ealcs.) kyAT.EX 11FA.I.�W,/ /EI.EC ENERGY PEE Y N I cerdfythat be the performance of thework forwhlch this permit is Issued, I shall not employ any person in any manner so a to become subject to the WATER SYSTEM/ TING Worker'Compensation Laws of California.Date PAID Z Z Applicant NhlV RE9D LPLMB. SQADate Rest t# Z O NOTICETO APPLICANT.If,after making this Certificate of Exemption,you Fshould become subject to the Workers'Compensation provisom ofthe Labor TOTAL: N Code,you moat forthwith comply with such provisions orthb perrwt shall be W 7 deemed revoked. BUILDING FEEx CONSTRUCTION LENDING AGENCY SEISMIC FEE tL Ihembyarftrtn that there b a construction lending agency for the perform- TOTAL: ` ELECTRIC FEE D Z 'once of the work for which this permit Is Wued(See.3097,Cb•G L cV/ V O Lender.Name PLUMBING FEE LL I- Lender's Address QTY.I MECHANICAL PERMIT FEE MECHANICAL FEE r'0 OW Icertitythatl have read thbappBatiunand matethat theabove information a bcorrtx.1 dgreeto comply with all city and countyordinances and mate laws PERMIT ISSUANCE 1.2(i/ FEES PAID: } odMingtobuilding coretructian,ana herebyauthodze reprexntatives ofthb �-s H N city to enter upon the abuvementioned Property for inspection purposes. ALTERORADDTOMECH. 1eW Z Date Recei t# _ (We)agree to jade,indemnify an d keep which the 1.a or Cupan im P against liabilities,jadgnante,comsand expenses which may In anywayacoue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: asst old City N (t conaryuena o(thegnnting this period. /0 S() AIR HANDLING UNIT(OVER 10,030 CFM) CONSTRUCTION TAX gnature of Applicant/Contractor Dnle EXHAUST HOOD(N/DUCT) CONSTRUCTION TAX PAID: - HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t# 3a� material as defined by the Cupertino Municipal Code,Chapter 9.17,and the Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: ❑Vea M No Wlllthe eppllant or town,building ottvpam use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE which emit hazardous air contaminants as defined by the Bay Area Air rA R/� Q11a.lity Management District? BOILER-COMP OHPOR 101,000 BTU( AAff�� YeaNo have read the hat,9 s materials requirements under Chapter 6,95 of BOILER-COMP(OVER 100,000 BTU) (1 the California Healt h&Safety Code,Sem ions 25505,75533 and 25534.1 our. • ga, � Y understand that If the building does nmcomantlyhaveatenangthat it hemy NEW RESIDENTIAL MECH. SQ.FI. pruntoWsuance notify the accvpanlofthe requlrementa which must be nod responsibility espons haste o(a Cerliftate of Oocvpa rey. Owner or authorized agent - Date TOTAL: ♦w ISSUED BY. OFFICE COPY