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20670 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PERMIT NO Building Address: /�O O 67' a3 o�s� G nere U t ` one: A A a {"^ CITY OF CUPERTINO-BUILDING DIVISION Comouter'.N. : Lic.Nan APPLICATION / PERMIT 91 )0-90 Arcldtect/Engineer. Llc.N. BUILDING-ELECTRICA PLUMBINGMECH LAICAL CATEGORY CONTROL M � QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Add. PFRMITISSUANCE 1:1 ❑ ElLICENSED CONTRACTOR'S DECLARATION I hereby affirm that l am Bcerued u oder provisions of Chapter 9(commenc APPLIANCE-RFADENTIAL JOB DESCRIPHDN ingwith Seaton 70(0)0fl3whdan3ofthe Buslneuanndd ProfosionsCode,and m license is In 1u11(orq Ygdeffect.., �nQ PANELS DansC%�L�LI Contractor Dated` �J/ FlRE9�AC� L�N�2. ARCHITECTS DECLARATION a OVER00AMI'S 000 Iundersland rtry plan shallh used azpublie records. OVER 1000 AMPS 5(j.FT.FLOOR AREA 5/SQ.FT. a Licensed Professional SIGNS ELECTRICAL Zp al OWNER-RUILDER DECLARATION y.Jaz Ihercbya(firnthat]am caemptfromthe Contranor's License Law Earths SPFLLILCIRCUIT/M15C followingon.(Saction 70315,Business and Professions Code:An d m y ty TEMP.METER OR POLE ST. CE countywhich rcqulresapermittomvtmn,ilter,improve,demollah,orrepair .0 anystrutlure prior to its tatuance,abo requlrestheappliant forsuch permit to file a signed statement that he Is licensed pursuant to the provislov of the POWER DEVIC 3w ContractorsLicenselaw(Chapter9(coruroncingwlthSenion7000)ofDivl- f,�0a sion3ofthe Businessand ProfessionsCode)orthathetsexempttherefvmand SWaiMIN �' VALUATION �'•an the basis for the alleged exemption. Any violation of Section 7031.5 by any � 0G applicant for a pcHrot subjects the applicant to a civil penalty of not ore than OUTLETS FI / na11. 0A VV five hundred dollars($SM. ) IDD- 00 DD �j.. ❑I,as owner of the property,or my employees with wages as their In NE RESID L E TR SQ.IH'. STORIES TYPE CONSTRUCTION 6 compevatlon,wllldo the work,and the structure Is not intended or offered for p sale(Sec.704y Business and Pmfessiov Code:The Contractors License Law S.S does not a pply to an owner of property who builds or improves thereon,and OCC.GROUP RES.I1MT5 who does such work himself or through his own employees,provided that such Improvements arc not Intended oroffcred forsale.If,however,lhebuilding or "VENT TOTAL: improvementbaoldwithlnoneyearofcompinion,theowner-b gderw111have tl�urden of provingthat he did not Wild orlmprove for purposeofsale.). QTY, T FEE FLOODZANE APN LJ L as owner of the property,am exclusively contracting with licensed contractors tocovtma the project(Sea7044,Businessand ProfessionsCode: FER The Contrector's License law does nor apply to an owner of property who ALTDRAINA) Wilds or Improves thereon,and who contracts for such plojem with a cgtS,aaor(s)licensed pursuant to the Contractor's Lkenm Law. RACY FLOW PROTECT.DEVICE FEE SUMMARY L5 I am exempt under Sec. B k P C for this mason DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y— N_ OUTSIDEFErs Owner Date RECEPTY yJ WORKMAN COMPEVSATION DECLARATION FD gPER TRAP SCHOOLTAX Y N dl hereby affori that I have ocertificatel coof consentamnifi to pythe re or a RECEIPT Y dials o(Workeri Campensatloninsuranmoracertlfled capythertn!(Sa. GAS EA.SYSTEM-1 3503,lab ) PARK FEE Y N C. I D f �67+ RECEIPT p Cam cAt GAS EA.�a Or t'14 BUILDING DIVISION FEES 1 (Certified copy b heed with the cit. GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE Certified copy V(Ikd with the tlty inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWER-SANITARYEA 2(IOFT Date RCCCI t# UNswnion neM not M completed if the permit l9 for ons hundred dollars (51I mrtify that WATER HEATER W/VENT/ELECTR ENERGY FEE Y— N I certify that N the performance of the work forwhlch this permit Is bound, — I shall not employ any person In any manner m as to became subject to the WATER SY571M/TREATING 0 Applicant orken'Compamoti..iaw.of Callfomla.Date PAID Pp NEYRESIDENTIALPLMB. SQ17, Date Remi t# Z Q NOTICEould ca APPLICANT:a corkers-Comp rCertlfiateof Exemption,you F ande,you=at forthwith the Workers'such pmzHonprovbiovrmitofthes Lab be TOTAL: N Codeyouvoked.rthwith comply with such provlaiov orthb permitahallbe BUILDING FEE r70 � j deemed revoked.W O CONSTRUCTION LENDING AGEVCY SEISMIC FEE CL Ihereby af0rmthat them la a mruwnion lending agency for the perform. ELECTRIC FEE Z mace of the work for which this permitiss is ued(Sec.3097,Civ.C.) TOTAL: VOLander.Name PLUMBING FEE LL ~ Lender.Addreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE O W l cuAlfythat l have read thisappliation and stmethat theaWve information umrmct.l agree to comply with all tltyand countyordinaneasand state laws PERMIT ISSUANCE FEES PAID: r 6 relating to building roretructlon,and hereby authorm,representatives ofthb F U) city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH. (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt# V against liabilities,jud s ntRpte I.rorts and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: gal Id CBy In �Cea a..mt-of`thee granting of this permit. tV� �—/O,S(I AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX Sign K.i Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DI SCLOSII RE Will the appil"at or future build Ing occupant store or hand le hazardous HEATING UNIT(TO 100,000 BTU) Date RCCeI t# material as defined by the Cupertino Municipal Code,Chapter 9.14,and the - Health and Safety CW5.ytlion 75532(a)7 HEATING UNIT(OVER 100,000 BTU, TOTAL: U Yrs o Will the a pplla of or lure building occe pant use equ 1pment or devices VE'MLATION FAN(SINGLE RESID) I$SUQIV[g DATE which emit havrdous air contaMrunb as defined by the Bay Area Air rE''+��A6� Qu lily Mavgamcnt n7 BOILER-COMP pHPDR 100,000 BTU) 4Yes No have read theh ousmaterialsrequitementsunder Chapter 6.95 of BOILER-COMP(OVER 10opW BTU) ♦ 1 8 1990 the—aurnla Health A Safety Code,Sen lav 75505,25533 and 25534.I 1 JJ u nderstand that if the building does not currently have a tenant,that it b my NEW RESIDENTIAL MECH. SQ.FT. responsibility to nal .occupant of the requircroe.tewhich must be rmet ri to assn ofa rtl' to ofoccupa my. City Of Nvertiflfl P rz q C��s Ow er or authors agent Date ISSUEDRY: t TOTAL: OFFICE COPY