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20262 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY Building Project Identification Bulldog Addres/ PERMITNO. ^ tress 0 G G G waro a one: 654 CITY OF CUPERTINO-BUILDING DIVISION APPLICATION / PERMIT UA A A A -9- c°ntractor'aName: Q r Lie.No: Y CATEGORY CONTROLN Amh4m/En 2 3-c23c�9 Lit. No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INF C Address: p„t, pERMITISSUANCE ❑ LICENSED CONTR CTOR'SDECLARATION I hereby affire that l amllcrosed under provWonsof Chapter9(con.c ingwlth Section 7000)of Dlvlsion3ofthe Buslne isand Prole,emesCode, and my Itcense b In full fo and affect. License Class Lic.p APPUANCESRESIDENTIAL JOBDESCRflMON PANELS Date Conlactar ARCHITECPS I understand my ptsns a used pern s. / /3%/)'a / 201-1000A.MPS - OVER 1000 AMPS SQ. FI. FLOOR AREA $ SQ. SIGNSELECTRICAL Licensed Profealovl OWNER -BUILDER DECLARATION I herebyaffirm that I am exempt from the Contractor's License Law for the following eastern. (Section 7011.5, Business and Professions Code: Any city or county which requmesa permittocorstact, alter, improve, demolish, oreepair anystmdurepriortoitsbeaance,ahorequimstheapplluntforauchperMtto file a signed statement that he Is Bcensed pursuant to the provisions of the Contractor's License Law (Chapmr 9 (commencing with Section 7000)of Divi— Mona of the Business and Professions Code) or that he b exempt therefrom and the barb for the alleged exemption. Any Violation of Section 70315 by any applicant fora permit subjectathe applicant to a civil penalty of not more than five hundred dollars (SSW). ❑ 1, as owner of the property, or my employees with wages as their sole compensatlorywillciothe week, and the structure b not intended or offend for ' SPECIAL CIRCNT/MLSC 7g{p.MEI'ER ORI'O1.E INST. POWERDEVICES VALUATION nC/� �• C OUTLETS -SWITCHES -FIXTURES ♦ NEW RESIDENTIAL ELFCTR SQ.FT. TORIESTTE CONSML•CTION sale (Sec 7094, Business and Professiare Code: The Contractors Lim. law does not apply to an owner of property who Wllds or improves Ihereory and who does such work himself or through his own employees, provided that suchOCC.GROUP improvements am not intende i c roffBred forsale. If, however, the building or Improvement issold withinoneyearofcompleiorytheowner-builderw8l have thf,jia rdenofpeoving that he did not build or improve forpurposeofsale.). "L as owner of the property, am exclusively contracting with licensed rontractors to mnsHuct the project (Sec. 70K Business and Profusions Code: The Contractor's License Law does not apply m m owner of property who Wild. or improves ehereory and who contracts fon such plojecta with a ctt actor(s) licensed pursuant to the Contractors License Law. LJ I am exempt under Su. B A, P C for this mso an AES. UNITS TOTAL: QTY. PLUMBING PERMITFEE PEtMH15SUANCE nye � lJJ gygm-DRAIN A VENT -WATER (EAa Q s FLOG ZONE APN FEE SUMMARY QI1Tq1 11F EEL BACK FLOW PROTECT. DEVICE Owner Dace WORKMAN COMPENSATION DECLARATION 01 hereby affirm that I have a urtifiute of consent to self -insure, or a certificate of Workers'Compens mon Insurance ora certified ropy thereof (Sec. 3800, Lab C.) Policy Y DRAINS FLOOR, ROOF, AREA, GOND. 5 SANITARY Y N_ RECEIPT Y L FDnURE`-PER TRAP L' (ySCHOOL TAX Y N_ RECEIPT M GAS EA. SYSTEM -1 INCA OUTLETS PARK FEE Y N RECEIPT Y #BION Com any GAS EA. SYSTEM -OVER 4 (EA) BUILDINGCEIPT FEES ❑Certified copy b heed with the ed.city ❑CertUied copy b filed with the city inspection division. GRFASE/INDUSIEL WASTE INTERCEPTOR PLANCHECKFEE CERTIFICATE OFEXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Thiaseetionneed not becimpleted lithe permit bforone hundred dollars ($I W)or less.) GREASE TRAP PAIDCp Date RCOCI (# SEWER -SANITARY -STORM EA 2a(FT. WATER HEATER W/VENT/ELFCTR ENERGY FEE Y_ N— I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so 'o the Worken'CS f�ka, PAID WATI7SYSITM/TREATING NEW RESIDENTIAL PLMB. SQ}T, •� ._ NOTICE TO MPLICANT:It, after making this Certifeate of Exemption, you should bcmmesubjccttothe Wmken'Compmxxjjn provbionsofthe Labor Cede,you mustforthwithmmpiywithauchprovlsiomorthisper tshallbe deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there b a construction lending agency for the perform- ante of the work for which this permit is issued (Sec. 3097, Civ. C.) Lender's Name Lender's Aaareaa I certify thatl have read thisappButionand statethattheabove information b cornet. l agree to comply with all city and county ordinances and state laws relating to building mnstactlon, and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. (We) agree to save, Indemnify an d keep harmless the City of Cupertino against liabilities, judgment, m is an expenses which may In any wayaccme agairestsald Ci In rons of a granting of this permit. Date Retti t# TOTAL: BUILDING •E TOTAL: ` SEISMIC FEE ELECTRIC FEE QT'y. MECHANICAL PERMIT FEE PERMIT ISSUANCE ALTERORADDTOMECH. AIR HANDLING UNIT (TO 10,000 CFM) PLUMBING FEE MECHANICAL FEE FEES PAID: Date Receipt# SUBTOTAL• AR HANDLING UNIT (OVER I0,IYXI CFM) CONSTRUCTION TAX ®S fSTFafum.i rat/Q nt t Dat S MATERIALS DISCLOSURE nithe appBunt orrcbuildingoavpantstoreorhandlehazardous material as defined by the Cupertino Municipal Code, Chapter 9.12 and the ilealth and SafetyCode icon 25532(a)7 ❑Yeso Wil emit the applicant or(umrcbuilding occupant use equipment ordevices whkheMthazardoua air root minants as defined by the Bay Arca Air Quality Management Dish 4 Yn No EX I US'F HOOD (W/DUCT) CONSTRUCTION TAX PAID: Date RCCCI t# HEATING UNIT HO 100,000 BTU) HEATING UNIT'OVER"10,000 BTU) 'OVER "1"'0" TOTAL: VENTILATION RESID) ISSUANCE DATE BOILER -COMP OHP OR 100,0(0 BTU) BOILER -COMP 100,000 BTU) have read the has. ousmaterialsrcquimm ntsundcr Chapter6.95ef the California Health & Safety Code, Sections 25505, 25533 and 25539. I understancithatifthc building does not currently have a tenant, that it bray requlmments which must be met r¢ponsibllliy to notify theW-—.29 prior to issuance ofd inry. N'EW RESIDENTIALMECH. SQ,FT, / - �q/ ,49 nein razedDate � � TOTAL: ISSUED if OFFICE COPY ell can BE i IviAY U J 1,, P� ULDG. INSPECITY OCTION DE T INQMER , l._ q 41' �F]. . APPROVED _�— IN ACCORDANCE WITH THE CITY OF r _ . " . CUPERTINO CODES AND ORDINANCES' DATE 2X12 36 4_z�-..SIGNED�� [ t i This set of paVLS ns andons t / / be kept on the job at a,l t-mas and it s unT /OZG G �c 1 ;��/ / c .bei i��.C�, E�— lawful to ma!;e ny caa1 P , on same W;Ih.;u, R.s or alterations w fucn permission from �. the buiidin: u; CJ %J,r si ^ :� o G .— /' .� �.�, .� o PL, C.h• t.( Pa t;no. / - The stamp;ag o .h :. SHALL N01 b,, ,.e ,l "' n na-pecilications ` nt, be an n approval of the v 'It any C14 d;uo. cin r, visi,.n- 0FRE COPY