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19822 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY ✓ Building Pro:ed Identification PF WT NO. Building Adflms,: 19822s q IIaO L /�'�DA-�f S/✓t/1-L mance hone: APPLICATIn7779MIlTZ=A CITY OF CUPERTINO-BUILDING DIVISION Cent.tnr,wme: - uc.N¢ APPLICATION / PERMIT • SVNO cie AI fG�Tr " BUILDINGELFiC7RICALI'LUMBING-MECIIAMCAL CATEGORY CONTROL Amhitet/Engineer. Lle.Na: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: PERWTISSUANCE LICE NS EDCONTRACTORS DECLARATION mo ❑ IDI hereby affirrn that Tam licensedunder provisions ofChaptcr9(commmc MPLIANCESRFSIDENTIAL JOB DESCRB10N Ingwlth5diono )ofDW,ion3oftheBusmmandProlnsoaCode,and my license Is In fuB f9ge a?nd effect. S r�p� PANELS ' 7 License Cla .�(rf_Lic.If �1 5 7 J 6 S , 7k Date /o. Contnnor L RC he SDE OVEWO AMPS {Qq�Z 1 n nd�, M taedysp Dicta OV AMPS, �.FT.FLOOR AREA 5/eJQ.FT. E PJ Llcen�sslga AGNS TRICAL fn< OWNEReBUILDER DECLARATIONI hereby SPECIAL CUIT owingrof@mthatlam31.5,Business fromthe Contractorns icenseCod:law fm the 0 9L following realm-qu to pea 1.5, and and Professions e=16h,y city or gFA1P.M LE I F4 muntywhure riortoas pamittommtrquirestheaprovent fors ch,ormitto O�� any atrvcturepdormlte Issuance,also regpursuaappBa.forsuchof permitto POWER DE'VT �� file a signed statement that he V licensed pursuant to the provlsioro of the w Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIM 30� LC VALUATION slon3o(the Businessand Proressloru Code)orthat hebexem therefromand the basis for the alleged exemption. Any violation of Section 70315 by anyOUTLE155WI XrURFS V+ y, QOS applicant for a perend"ubjects the applicant to a civil penalty M not more t ban ma,� v V • G 0 5� five hundred doll..(§500). NEW RESIDENTIAL ELECIR SQ.FT. STORIES TYPE CONSTRUCTION ❑Las owner of the property,or my employees with wages there sole �7a wIs&.tion,wut,louheworkf.i. sCde:Te isnot Contractor or License Law sale(See aptly to ainowner fpropeom who Wild.d.or iropme.Llceme law �js$ docs net apply toanowoer orp rough whonorimproovided eortand OCC.GROUP RFS.UNITS who does such work tinteff or ndedoroughhhowals.1(employees,p r theb thatsuchG b improvementsarcnot Intended earofco forsale.If,howevep deer ill have TOTAL: improvement is sold proving that one he id ove build or ire the a for purpose of sshave tl{,);urdenof wnerof the popeidnMbWld orlmp contracting with liens QTy. PLUMBING PERMIT FEE L,f L a,owner of the property,am exclusively contracting with licensed F100D ZDNE APN PERMIT ISSUANCE contractors to construct the project(See.7044,Business and Professions Code: The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT WATER(EA) builds or improves thereon, and who contracts for such ptpjet, with a FEE SUMMARY c9nitactor(s)licensed pursuant to the Contractor's License Law. BACKFLOWPROTECT.DEVICE LJ I am exempt under Sec B &P C for this reason OUTSIDE FEES DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N • Owner Date RECEIPT N WORKMAN COMPENSATION DECLARATION FLXTURTS�PER TRAP SCI'IOOL TAX Y_ N_ ❑1 hereby affirm that I have a certificate of consent to eel(-Insure,ora RECEIRT N eenifiateafWoromV Compensation Insurance or a certified copy thereof(Sec. GAS EA.SYSTEM-I INCA OUTLETS PARK FEE Y_ N 3900,Tab CJ RFL=N Policy N GAS EA.SYSTEM-OVER 4(FA) Coommpany N BUILDING DI VISION FEES 11eiGFiBed copy is hereby filed the city GREASE/INDUSIRL WASTE INTERCEPTOR - PLANCHECKFEE _rL�J4Cenlfied copy b flied with the city Inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-SPORM EA 200F7 Date Recei t# (This section need not be completed if the pernat a for one hundred dollars (SIW)or IoO) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_ I certify that tribe performance of thework for which this permit Is Issued, I shall not employ any person in any manner so as to become subject to the WATERSYSIFM/TREATING Workeri Compensation Laws of California. Date PAID O Z Applicant NEW RESIDENTIAL I'LMB. SQFI. Date Recei t# Z O NOTICE TO APPLICANT:If,after making this Certificate or Exemption,you N should becomasubjeet to the Workers'Compensation provision,of the Labor TOTAL: Code,you must forthwith comply with such provisions or this permit shall be, BUILDING FEE W deemed revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE Q Il Z I hereby affirm that there u a rotutrution lending agency for the perform- TOTAL: ELECTRIC FEE• pfd D �rce ufthe work for which this permit is issucd(Sec.309],Civ.Q ELECTRIC EEE 00 Lcnder's Name F 1.endces Address QTY. MECHANICAL PERMIT FEE LL O MECHANICAL FEE Icertifythatl have readthisappliationaM statethataheabove information O W isc.mi1agere to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID: } a relating rebuilding mrutractlon,and hereby authorize representatives of this nr/a� L.7 ��� F N city to enter upon the above-mentioned property for inspection purpose,. ALTER OR ADD Ila MECH. 2 Date Receipt# (We)agree to save,Indemnity an d keep es which the In a y Cupertino V against liabilities,Judgments,costaend expenses which mayln any way accrue AIR HANDLING UNIT(T010,000 CFM) SUBTOTAL: J against Old City in con of ages nti permit. AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX rotor ate EXFTAUSTHOOD(W/DUCT), CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DIS SUR Will the applicant or future building occupant set re or handle hazardous HEATING Utxgi(TO t00,W0 BIIl) Date Recei t# material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Ilealth and Safety Code�+.-Stection 25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL: ❑ Yea u No Will the applicant or future building occupant use equipment or devices VEMDLATION FAN(SINGLE RESID) y ISSUANCE,BATE which emit hazardous air contaminants as defined by the Bay Area Air F w- • Quality M.wgc..t D'alrit? BOILER-COMP OFB'OR 100,"BTU) 4hvesread the havagoomaterlalsrequlnmentsunder Chapter 6.95of 30ILERCOMP(OVERI00,000BTU) , blilll� U7J`t)j the California Iimlth&Safety Code,Sections 75505,75533 and 25534. I understand that if the building does not currently have a tenant,that it is my NEW RGSI DENTIAL MECH. SQ.IT. responsibility to nor l(y the ore pant of the requirements which must be rrxl Clt.r P` rr1^grtlnv priorto lssu mot a Certificate tOccupancy. 1 OwneTOTAL:rorauth da Date ISSUEDBY:Nc OFFICE COPY