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24080 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Proles Identification PTh'Q. O R V O Building Address: �G) ZZ%O ALM Ave em. ams: hone: A b . AA SMA ma kQoo�>4�, CITY OFCUPERTINOIIUILDINCDIVISION -��-�Z comeaeor's Narm a .Na: APPLICATION / PERMIT BLILDINGELFCTRICALPLUMBINC-MECHAMCAL CATEGORY CONTROL 1 zchuect/En Lie No: DEAe QTY - •ELECTRIC PERMIT FEE - BUILDING PERMIT INFO,;;;. Address, PFRMITISSUANCE ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION Lr Iherebyalfirm thatlam licensed under provolone of Chapter9(conunen<- APPLIANCESRESIDENTIAL JOB DESCRIPTION ingwlth Section7000)of Dlvision3ofthe Businessand Pmfeaslom Code,and my � ` l license lslaiul rre and effect. — PANELS VCiY1 Llcan .m n Date mtractor ARCHITECP$ E RA D:V 20ER1000 PS AM Z I understand my plansshall be a as public records OVERIWOAMIsS SQ.Fr.FLOOR AREA 5/SQ.FT. 0, SIGNS ELECTRICAL -^.U�j Licensed Professlovl <i1O OWNER-B UILDER DECLARATION L�jj (hereby affirm that l am exempt from the Contractors License Law for the SPECWLCIItCUIT/MIST �OJ9following reason.(Section 7MI.5,Business and Professions Code:Any city'' TEMP.MEIG¢ORPOLEINST. county which requires permit to construct,alter,Improve,demolish,or reps q,Zi S'j any swcture prior to its Issue ace,a lino requires the applicant for such permit to LOWER DEVICES :'S fio a signed statement that he is licensed pursuant to the provisiom of the IO_ Contractors License Low(Chapter 9(commencing with Section 7000)of Divi- PO SWIMMING OL ELECTRIC 0andP 5 sion3oftheBitunesamfosedmaCode)orthatheis,exempttherefromVALUATIO ami pyy I - the basis for the alleged exemption. Any violation of Section]0315 by any OUTLETS-SWITCHES FIXTURES OOO C-0 applicant fora permit subjectsthe applicant o a civil pewltyelf not more than j t m five hundred dollars($500). NEW RESIDENTIAL ELE-CTR SQ.FT. SI'OFOFS TYPECONSTRUCTION .. n 1,as owner of the property,or my employeeswith wages as their sole CZa campensation,wBldothework,andthestructumieen intended or offered for j p vle(Sec.7044,Business and Professions Code:The Contractor's Liereue Law es$ does not apply to an owner of property who Wilda or improves thereon,and OCC.CROUP RES UNITS who don such work himaelf orthratigh hisowe employees,provided that such improvements are not Intended orolfered forxle.If,however,thebuiiding or TOTAL Improvement issoldwithinoneyearofcompletion,theowner-WBderwill have z. th rden of pewleg that he did not Wild or improve for purpose.feale.). Qct. BI NG PERMIT""-, FLOOD ZDNE APV _I,as owner o!the property,am exclusively contracting with licensed P - R LSSVANCE contractors to construct the project(Sec 7094,Business and Professlom Code: The Contractor's License Law does not apply to an owner of property who AL -DRAIN&VENT-WATER(EA) WII s car Improves thereon, and who contracts for such ptojects with a 1� 'i acts('.) apw,uant to the Contractor's Liceax Law. BAUC FLOW PROTECT.DEV( :•':FEESUMMARY'/'_v Ica t u B&P for th reason �__ �PLRt� - � D NSFLWR,'POO , SAtI1TARY Y N rte Data RECE97 s ILe ANC �MSATION DECLARA ON FDMRpS PFR.�Ap SCHOOL TAX Y_ N_ he aflirm that I have a rertificate of conxm to self-Insure,ora RECERrT N to, BcaCompematlon Insurance or a certified copy therref(Sec. GAS EA.SYSfEIf-1 INCA OUTLETS PARKFEE Y N 800,Lab C.) RECEP T M Policy 0 GAS F.A.SYSTEM-OVER 4(FA) Com any BUILDING DIVISION FEES Certified copy o hereby furnished. GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE .Certified copy is filed with the city inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' I GREASETRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.20�T. DRIC Recei tk (Thissection need not W completed lithe permit o foram hundred dollar ($100).,I..) WATER BEATER W/VENT/E.ECTR ENERGY FEE Y_ N_ I artily that in the perforreame.f the work(.,which this permit is stand, 1 shall not employ any person In any morme s°as to became subject t.the WATER SYSTEM/TRUIING Workers'Compensation I aws of California.Date PAID O Z ApplicantNEW RE DENT AL FILMS. Q T. Date Receipt making Z NOTICE TO APPLICANT:If,cher tCertificate of Exemption,You 0 should become subject to the Workers Compemation provobns ofthe Labor TOTAL' N Code,you=at forthwith comply with such provisions or this permit shall be BUILDING FEE �• W > dPen1Cd`eVOlkeii" SEISMIC FEE CONSTRUCTION LENDING AGENCY fl (hereby work forwhhereoacomtmttdont gued(Sec.309,cy Civ. he peAortn TOTAL, ELECTRIC FEE Z ance of work brwMchtho permit obs,m(Sec.3097,Clv.Cd .. PLUMBING FEE LL O Laader'a Name - :MECHANICAL PERMIT'" �iFEE ly 0 I<nder's Aadrcu '� MECHANICAL FEE O w onect.Ia t I have readagree to with allcitynand dmartethat yordinancesa dgatelaws FEES PAID: t bailees complywo ,alndhereb authorize erprese and gate laws PERMIT ISSUANCE } U) cityrelating oenteru Pon t consove-nen,andberebyrtyodurcptionpurpo .(this HZ myW)tereon theasavementfy an d property for inspection Cit purposes. ALTER 0RADDTOMECH. Date RMCIPI# (We)agrre t'save,Indemnity an d keep harmless the City of Cupertino V age Wt Mttlsp'judgmem carts dexpenxs which may In anywayaccrue AIR FIAhT)LINC 11MT(TO 10,1100 CFM) SUBTOTAL: ag s Id cue 'a t e granting of this perm AIR HANDLING UNIT IOVER I0,W0 CFM) CONSTRUCTION TAX sig App want/Gun actor Date 92 IXHAUSTHOOD(W/DUCn CONSTRUCTION TAX PAID: HAlARDOUS MATERIALS DISCLOSURE HEATING UNIT t00,0006TU) Wllitheapplicant or future building occupant store or handle hazardous Date RCCCI tq material as defined by the Cupertino Municipal Cod,Chapter 9.12 and the health and SafetyCods Srlb,75532(a)t HEATING UNIT(OVER 10,000 BTI)) IOTA n Yes d No Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE which emit hazardous air contaminants as defined by the Bay Area Air Q.rality Management District? BORER-COMP OHPOR 100AU BTU) C L 4YesNo havcreadthe har2utmaterials requirementsunder Chapter 6.95of BOILER-COMP(OVER 100,000 BTU) the California Health&Sf BCode,Sedions2S505,25533and2SiM. 1 fly RESIDENTIAL MCCH. SQ.IT. ��� ,� U IJJ understand that lithe building does not current) have a tenant,that it b my L responsibility to notify the occupant of the requirements which must be met prior to Issuance of a Certificate of Occupancy. �,I Vv(Ln I II IV Owner or authorlmd agent Date TOTAL: ISSUED BY: OFFICE COPY