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19631 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY 1.01=01:90iol j PERMIT NO. 19631 er. teams: Phone: CATEGORY CONTROL# 2vw 8 e CITY OF CUPERTINO-BUILDING DIVISION G°^t d° Na Y7: tic. No: EBUILDINGELECTRTCALPLUMBINGMECHAMCAL . APPLICATION / PERMIT A ItM/Engineer. Lk No: QTY ELECTRIC PERMIT FEE TYI'ECONSIRUCTION OCC.GROUP RES. UMTS FLCODZONE Address: PERMITISSLANCE LICENSED CONTRACTOR'S DECLARATION SCHOOL TAX Y_ N RECEIPT N PARK FEE Y_ N RECEIT N I hereby affirm that l am licensed under provisions of Chapter 9(commenc- APPUANCESRESIDENfIAL Ing with Section 7(X0)of Division 3 ofthe Business and PrefcasionsCods, and my II«nae I. I. full fo dPANELS TOTAL: License � i. 6 BUILDING FEE YT. Date-��C°ntraRor QJy/aP/4.h/UP TO 200 ANTS 701.1000 AMT'S 2 O ARCHITECTS DECLARATION / Iunderstand my plans shaghe used as public records OVER1000AMPS SIGNS ELECTRICAL ZLicensed Professional Z F4F'u9 �m .c C r. 3 a L�, O< P •-t �J<5 OWNER -BUILDER DECLARATION I hercbyafftrm that l am exempt from the Contractor's License Law for the fallowing reason. (Sevit. 7031.5, Business and Profession. Code: Any dtyor county which require a permit tumnstrud, alter, im F prove,demoilsh,orre air anystmt mpdortoibtswame,aWrequirestheappliantforsuchpermitto ilk a signed statement that he b licensed pursuant to the provisions of the Contradorb License Law (Chapter 9 (commencing with Section 7000) of Divi- slon3ofthe Business and Prosmkxrs Code) orthat heisescmpttherefmmand the bests for the alleged exemption. Any violation of Section 7031.5 by any applicant for a pertNt subjects the applicant to a civil penalty of not more than SPECIAL CIRCUIT/MLSC TEMP. METER OR POLE INST. ('OWER DEVICES SWIMMING IDOL ELECTRIC OUTLETSSWITCHESFlXTURES NEW RESIDENTIAL ELECTRSQFT, C'/Q $ ❑ ($$ 0. five hundred dollars ❑I as owner of the , property, or my employes with wages a. their sole compensation. wlRaothe work, and medrudumbnet imentied or offered for sale(Sec.7044,Business and Professions Code: The Con md.e. License Law does not apply to an owner of propertywho builds orimprove. thereon and whodoessuchworkhm lforthmughhlsownemployer, pmvidedthatsuch TOTAL: 137 rV ISSU�ftATE FEE 13 hSJ City Of cgngrtjBm ISSUEDBY: improvements are not intended oroffered forsals. If, however,thebuilding or improvement issold within oneycarofcompletl°n, the owner-bu tlderwlll have TOTAL: t rdenof proving that he did not build or improve for purpose ofsale.). 4 as owner of the property, am exclusively contracting with licensed contractors to mmtmd the project (Sec. 7044, Business and Profmsbts Code: QTY, PLUMBING PERMIT FEE PERMIT ISSUANCE The Contmdor'. License Law time not apply to an owner of property who or improvm thereon, and who cordrad. for such projects with a pLTpi-DRAIN & VENT WATER BIM c78$pador(s) licensed pursuant to the Contractors License Law. , I am exempt under Sec. B & P C for this reason BACK FLOW PROTECT. DEVICE DRAINS FLOOR ROOF, AREA, COND. Owner Date WORKMAN COMPENSATION DECLARATION ❑1 hereby af0um that I have certNste of consent to self -Instars, or MTURES PER TRAP o ytherea . MOOL"HIficate bC') rkers'Compensatlonlnsurance oracertified copy thereof(Sec. 3B00,Iab C.) Paltry Y GAS EA. SYSTEM -1 INCAOITLETS Com env L %�t Our Q"'3p GAS EA. SYSTEM -OVER 4 (EA) 1 �Certiflc co� ledwcre thmohy. �Certiflh copy b flied with the city inspection division. GREASE/WDUSIRL WASTE INTERCEPTOR CERTIFICATE OF EXEM PFION FROM WORK ER S' GREASE TRAP COMPENSATION INSURANCE (Thissedionneed not bscomple A ifthepermit bforone hundred dollars SEWER -SANITARY -STORM EA. 700FT. C✓ Z Q W j aO (S100) or IcaJ 1 certify that o zhe any personIn a°f the work fors I.which this eestnit is both, I shall not employ any person in any manner n s I. become subject to the Workers Compensation Lawn of California. Date Applicant NOTICE TO APPLICANT.If, after ma king this Certiflote of Exemption,youshould become subject to the WorkersCompemat Ion provisions of the Labor Code,you roust forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirmthat there ls a corutruction lending agency for the perfmcn-TAL:O arses oftheworkfor which this permit b issuy(See. 3097, Civ. C.) ).ender. Name WATER HEATER W/VENT/ELECTR WATER SYSTEM/TRFATTNIO M=-ALPWB..FT.Z FEE IL H LendersAddreas OW } 4 H Z 1rertify thatt have read thlsapplica0onand statethetheaboveinformation Lsmrrect. Iagreeto comply with all city ami county ordinances and state laws relating to building c°mtrudlon, and hereby authorize representatives of this city to enter upon the above-menti°ned property for inspection purposes. (We) agree to save, indemnify an d keep harmless the City of Cu pert Lro agaLstllabiW judgment --:M as despenaeswhlch mayin anywayarcoe agajagt.`id i incone hegranting o(thla Ptmrut ALTERORADDTOMECH. ATR HANDLING UNIT (TO 10,000 CFM) A R HANDLING UNIT (OVER t0,000CFM) 1/ {/1 M Slgmttrc of ApplC0 Date HAZARDOUS MATERIALS DISCLOSURE EXHAUST HOOD (W/DUCT) BEATING UMT(TO 100,000 BTU) Will the appUcant or rertino h, by material a. Safety by the Cupertino Municipal Code, Chapter 9.17, and the Municipal Ceti, Chapter and 1 -(EATING UNIT (OVER 100,000 BTU) Hslthand Safety Code Ion 75537(a)7 LIJ No VENTILATION FAN (SINGLE RESID) viccs Wlllthe applicant or futurebtildinga.defi which emitharardomalr cont ,vote as deBny by the Bay Area Alr cdbythr B,y .a AI BOILER -COMP OIiP DR 100,000870) Yc. No 4uy Mawgerrcnt Dlstou BOILER-COMP(OVER 100,000 BTU) have read the baza s materials mqulrerrcnta undcrChapter 6.95 of the Calffcrnia Health & Safety Code, Sections 75505, 75533 and 25534. I NEW RESIDENTIAL MECH. SQ.FT. understand that if the building does not currently have a tenant, that it is my responsibility to notify the occupant of the requ Immenls which must be met prior to osua oce of a Certificate of Occupancy. Owner or authorized agent Date 1.01=01:90iol j PERMIT NO. 19631 A A CATEGORY CONTROL# BUILDING PERMIT INFO JOB DESCRUMON C�irnne �e SQ. Fr. FLOOR AR //SQ. F7. VALUATION l (Ooo 0 STORIES TYI'ECONSIRUCTION OCC.GROUP RES. UMTS FLCODZONE APN FEE SUMMARY SANITARY Y N RECEIPT 0 SCHOOL TAX Y_ N RECEIPT N PARK FEE Y_ N RECEIT N BUILDING DIVISION FEES PLANCHECK FEE PAID Date Remi t# ENERGY FEE Y— N PAID Date Remi of TOTAL: BUILDING FEE YT. SEISMIC FEE ELECTRIC FEE PLUMBING FEE MECHANICAL FEE FEES PAID: Date Receiptfl SUBTOTAL: CONSTRUCTION TAX CONSTRUCTION TAX PAID: Date Reoei tN TOTAL: 137 rV ISSU�ftATE FEE 13 hSJ City Of cgngrtjBm ISSUEDBY: