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20746 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Pro'act Identification PERMIT NO. BUBdiag Address: - 20746 1 Or (O�O� me�:.^ Q APPLI III EALUAII, CITY OF CUPERTINO-BUILDING DIVISION ca dar',Na r: • 2 le.No APPLICATION /'PERMIT L YY)h4j&Pr%r 7 J - BMLDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL# Archiled G�J+nrer. Lk No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT.INFO Address: _ LICENSED CONTRACTOR'SDECLARATION PERhtTISSUANCE E 1:1 D T hereby affirm lhtfam@ewnd under provblana o(CFapter9(wmmene APPLIANCESRRSIDENTIAL JOB DESCRIPTION ingwith Sedion 7000)of Divisim3 ofthe Businmsand ProfosionsCode,and my - Ikxnse Is In fy�L( d dfed. (�- ^yr-�ry PANELS Li..r ClassCi _Lic.N 7j-(0_4" _ �i•�,)- 1 ",— Date ^. Date Contra r 2011000 AMPS 1 1_l.V_jv ' ARCHI=S DECLARATION �7 reco I understand my plans shall W used as public rds ' OVER 1000 AMPS SQ.FT.FLOOR AREA 5/SQ.Ff. O dF Licensed Professional SIGNSELECTRICAL OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC I berebyafRrm that l am exempt from the Contractors License taw for the _ 0p-- fallowing mason.(Section 7011.5,Business and Professions Code:Any dty or TEMP.METER OR POLE INST. apppp county which requires a permit to roralrur4,alter,improve,demolish,or repair _ F1 .'rs any structure prior to Its Issuance,a Iso requires the applicant for such permit to POWER DEVICES _ E K file a signed statement that he Is lira eed pursuant to the provisions of the pOlOu, Contractor's License Law(Chapter9(conurendng with Section AX0)of Divi- SWIMMING POOL ELECTRIC ston3ofthe Buslnessand ProfeesloroCode)orthathebmevethercfromand VALUATION ^a the basis for the alleged exemption. Any violation of Section 7031.5 by any / Q© Q QSOUTLETSSWITCFIFSFIXTURFS l aa� applicant far a permit subjects the applicant toacivil penalty of not room than 6 0 five hundred data.(SSW). E]1,as owner of the property,or my employees with wages as their sale NEW RESIDENTIAL ELEC7R SQFT. STORIES Tri'E CONSIRIKTION compensation,will do the work and the structure in not Intended or offend for $a O wIs CSac.7014,Business and Professions Code:The Contradoes Llmnse law FSB does not apply to an owner of property who builds or Improves thereon,and OCGGROUIs R13.UNITSc. who does such work himself or through his own employees,provided that such Improvements a.not Intended oroffered for sale.If,however,the building or TOTAL: Improvement is sold within one yearofcomple0on,the owner-bullderwlll have t"rden of proving that he did not build or Improve for purpose of isle.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN U L as owner of the property,am exclusively contracting with Ilansed PERMIT ISSUANCE conlrado.lo construct the project(Sec.7044,Business and Professions Code: The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN 4 VENT-WATER(FA) Wilds or Improves thereon, and who comrade,for such p(a)ects'with a FEE SUMMARY CgDlfactor(s)hmosed pursuant to the Contradm'e Ll.nse Law. . BACK FLOW PROTECT.DEVICE LII am exempt under Sec B A P C for thin masonOUTSIDE FEES Owner Date DRAINSFLOOR ROOF,AREA,GOND. SANITARY Y_ N_ • WORK MAN COMPENSATION DECLARATION RECEIPT N FIXTURES PER TR" SCHOOL TAX Y_ N_ ❑f hereby affirm that I have a mrtlRcate of consent m set(-insure,ora RECEIPT N mrtiftcate ofWorkers'Compevalionlwurance or a certified copythe.of(Sec. GAS EA.SYSTEM-11NC.d OUTLETS PARK FEE Y N dC.) RECEIPT# PoolleylicyN p ' GAS EA.SYSTEM-0VER 4(EA) - Com any BUILDING DIVISION FEES ECedlfidcopyishercbyfurnished. GRGASE/INDUSIRL WASTE INTERCEPTOR FEE ❑Certified copy is filed with the city Inspection division. CERTIFICATEOFEXa PTIONFROM WORKERS' GRFASETRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA,200FT. Date Rami of (Thissectlon need not he completed if the permit is for one hundred dollars ($100)or less. - ' WATER FTFATQi W/VENT/ELFCTA ENERGY FEE Y_ N_ Imrtifyth ntheperfonmarmofthcworkforwhic thisp It is issued, I shall note �y any on In any manner ro the WATER SYSTEM/TREATING workers' a f la of ouramla.Dme_ - .. PAID APPlican �o Date Remi tN ZZ NOTICE TO IC rafter makingthisCertificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FT: O ,hwld beamesubjed t orkero'Compewtlonpmvbiomofthe LaWr - TOTAL: ~ N Code,you=atforthwith comply with,uch pmvisima,mthis permit shall be 3 j deemed revoked. - ' UIING FE• 111 - CONSTRUCTION LENDING AGENCY - SEISMIC FEE tso — a Iherebyaffirmthzt there usemiawdlon lendingagency forth perform TOTAL: ELECTRIC FEE ' 7 Z ante oflhework forwhichthin Fermat b Lssard bre.3W7,Civ.C.) UO Lnedera Name PLUMBING FEE LL1= Laroder',Addres, QTY.I MECHANICAL PERMIT 'FEE_ MECHANICAL FEE Q Imrflythat l have read thisappRcationand state thattheabove information O W Is correct.I agree to comply with all dty and county ordinances and state laws PERMIT ISSUANCEFEES PAID: >. 0' relating to Wilding construction,and hereby suburban representatives of th is cit to entero n the aleve-mmentioned! forW Ion ALTERORADDTOMECH. H Z y I� P�ttY he purposes. Date Receiptk - (We)ar o vave,Indemolfy an d keep harmless the in a ywaya erne Q agaimtllsbll le jadgmanb,costs and expenses which may In any wayaccrve AIR HANDLING[JMT RO 10,000 CFM) SUBTOTAL: gaI ns said it lumnsryue ofthe gr an it of thi perm) AIRHANDUNCUNIT(OVER IB,BBocFM) CONSTRUCTION TAX Igoa igmmmo A pll nt Cant ad r EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: H RD MATERIALS DI SC LD SU E Willthe applicant or future bu0ding arupantstore or handle haurdous HEATING UNIT(TO 100,0(10 BTU) Date ReceI tN material as dented by the Cupertino Municipal Code,Chaptcr 9.lZ and the Hcalthxnd Safety Cde Sealon25532(a)4 HEATING UNIT(OVER 100,000 BTU) TOTAL: (� ❑Yes MN. - Wliltheaplicantonfuture Wilding occupant use ryuipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE which emit hazardous air contaminants as defined by the Bay Area Air Qu Pity Management District? BOILER-COMP Ott'OR 100,"BTU) F� Yes No (' 'TIvc.adthehuausmatcriabmquimmntaunderChapter6.950f• BOiER-COMP(OVER 100,000 BN) + 7 n Igo the California Health A SaftyeCode,Sections 25505,25533 and 25534.1' JL w �� f unde.m ndl the build ing does not currently have a lens nL that it is my NEW RESIDENTIAL MECH. ' SQ.FT. raporuibilit tofytheoceupantoftherequiremenlswhkh ust be 41F 'arta u da Corti of Occvpanay. ^ - -1 �{/'� tie �/{�}(� Owner or authorizedAnt to TOTAL: ISSUED BY:��UC(/���1'�'r s`•'`�`^-^� OFFICE COPY