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19813 (2) APPLICANT TO FILL IN INFO RMATION.WITH IN'RED LINES— USE BALL POINT PEN ONLY Building Prom Identification PELMITNO. Building Address: 1 9 8 1 3 og3a Q. vy- came: Phone: �er. r) VLV. 'D - CITY OF CUPERTINO-BUILDING DIVISION e�nnn<��na�nr. came Lk.No: APPLICATION I PERMIT r ) - \ 'qD BUILDINGELECTRICA PLUMBING-MECHANICAL CATEGORYCONTROL Architect/Engine. Lk. o QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Add.. ��PERMITISSUANCE I ❑ El F-1LICENSED CONTRACTOR'S DECLARATION I lath b ion7Oaffirm,thatfDtmsicrnrefth dB. .ro...nsoffe son C(mmmrne- APPITANCFSRESIDENML JO DFSCRB'770N Ingwith Section 7W0)ofd diedn3o(the Butlnemand Pro(eWonaCode,and my Iicenm laiefull force and—LIC.If PANES LicenDate Clam Lic,p Date.Contractor -,UK ARCHITECT'S DECLARATION 201-1000 AMPS p�p�uu a0 Q I understand my plans shall be used u public records. OVER 1000 AMPS SQ.FT. R AREA S/SQ.F9. biz Licensed Professimal ECNS ELECTRICAL I N 6 rg OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/M z Iherebyaffl mthat lam ezemp fromthe Contractors License Law feethe pp following reason.(Section 7035,Business and Professions Code:My city or FE ty cauntywhkhrequU aper tWcomtmcctaller,lmpmve,demollah,ormpalr �MP'METER OR POL m '3 any strurmre prior to its Issuance,also requires the a ppllant for such permit to POWER DEVICES- O a0 6 file a signed abutment that M Is licensed pursuant to the provisions of theDATE u,lin Contractor's License law(Chapter9(commencing with Section 7000)of Divl- VALUATION OS cI.n3 of the Business and Professions Code)orthat he Is exempt therefrom and SWIMMING PODL C the basis for the alleged exemption. Any violation of Section 70315 by any p applicant/ora permit subjectstheapplicanttoa Civil penalty ofnat nrethan OU'ILELSSWITCHESHKTURES n five hundred a sr owner of the property, NEW RESIDENTIAL ELECIR SQ.FIL STORIES TYPE CONSTRUCTION ❑I,as owner of Ilse property,or my employes with wagon as offered sale - ` 7< Ole(Se compensation,Businessl do and Prwork,and the ssions structure h Contraonlistended or cense Lar D sale(Sec.7044,to anowandf property Code;The Comranors I hemon law _ 1 docs does apply torn irmadner ofpropgh hi.m .em who oy.,pr nlMreon,and OCC.GROUP RFS.UMTS EE who doementsa not tintendedcrwgh hhownemp,howev calashovided ildinghat r improvementsarenmintended earofco foraek.If,however, oder i)iWve TOTAL: Improvement Isaold withinoney.arolcompletlon,tMowner-bu0derwill have � - a ttill.korden of proving that M did not build or improve for purpose of sale.). QTY, PLUMBINGPERMIT FEE FLOODZANE APN Lj 4 as owner of the property,am exclusively mmncbng with licensed PERMIT ISSUANCE - contractors to construct the project(Sec.7W4,Business and Pmf ssions Code: The Contractors License Law does not apply to an owner of property who ALTERDRAIN kVENT-WA'fpt[FA) Wor improves thereon, and who contracts - fee such Toplacts with a - FEE SUMMARY ,xiaLpetor(s)licensed pursuant to the ContractorFL Contractor's Llmn.o Law. BACK AW PROTECT.DEVICE 1_J I am exempt under Sec. R k P C for this reason OUTSIDE FEES DRAINSFLOOKROOP,AREA,CONTI. SANITARY Y N_ Owner Date RECEIPT If WORKMAN COMPENSATION DECLARATION FATURE&PER TRAP SCHOOL TAX Y N ❑I horeby or( r.that I have o lmumne of consent d spythmre,ora RECEIPT p certificate of Workera'Compersatlonlwunnce ma certified spy thereo!(Seo. 3500,Lab CJ GAS EA.5YSTEM-1 INCA OUTLETS PARK FEE Y N ' RECEIPTN Policy p GAS-F.A.SYSTEM-OVER 4(EA) Ca���������m000000any BUILDING DIVISION FEES C. ed spy is hereby furnished. GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE Certified copy Is filed with the city inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWER-SAMTARY-STORM EA.200FT. Date RL'Cel t# (ThlaaecEm need net M completed if thepermit Islorom hundred dollars (9100)orlem.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N I certify that In the performance of thework forwhich this permit Is Issued, I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING Wokers'Compensaticn❑Wsof Callfornla.Date PAID - z Z Applicant NEW RESIDENTIAL PI.MB, SQFT. Date RST!E!# Z O NOTICETO APPLICANT.If,after trading this Certificate of Exemption,you should become mbfect to the Worken'Comperwtion provisions of the Labor TOTAL: CC N Code,you at forthwith comply with such provisions orthis permit shall be I W > deemed revoked. ' EE CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE Iherebyaffirm that there I .centimeter,lendingagency forthe perform- TOTAL: ELECTRIC FEE D Z ance ofthe work ferwhich this permit is Wood(See3097,Ci¢CJ V O Lender's Name PLUMBING FEE LL H lenders Addreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE OW 1cotilythat l have read thlsapplicatienand slatethattheaWve Information (LI WI, l ageeeto comply with all dtyand county ordinances and state laws PERMITISSUANCE FEES PAID: >. relating to building construction,and hereby authorize representatives ofthIs F N city to enter upon the aMve-mentloned property for inspection purposes. ALTERORADDTOMECH. Z Date Recei t# _ (We)agree to rove,IndemNfyandkeepharmless es whihthe City o/Cupertlna against lBbllitke,Judgmenla,roateand expense which may in anywayacerue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: ago Wt said City In consequence of the granting of this permit. AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUCTION TAX Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the app0ant orfutum building occupant store or handle hazardous HEATING UNIT(TO 100,01O BTU) Date Recei t# material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Fl❑YedSafety Code SSecton75532(¢)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: Z.C� Will the x ppilcant or future building occupant use eiulperenl or devices VENTILATION rAN(SINGLE RESID) ISSUANCE DATE which emit hazardoua air contaminant.as defined by the Bay Area Air Quality Management District? BOILER-COMP OHP OR 100,010 BTU) - ❑Ya ❑No I have read the hazardous materials requirements under Chapter G95 of BOILER-COMP(OVER IWM BTU) the Califomla Health k SafetyCode,Sections 25505,25533 and 25534.I t understand that lithe building does net currently have a tenant,that it b"my NEW RESIDENTIAL MECH. 9Q.FT �]!1 responsibility to notify the ce.Team of the requirements which must be ort prior to issuance of a Certificate of Occupancy. '^'TT..,,����++ �� -r.�� �,,.. { (Tuner or authodred agent Date - ISSUED BY q)S— RtX N�"`+�M TOTAL: OFFICE COPY