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20529 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY • Building Project Identification PL MITNO. BuOding Address: 20529 Mrs Name: one: w a�b .- CITY OF CUPERTINO-BUILDING DIVISION C999ppptract"' Nan c: u".N APPLICATION / PERMIT CC lI// VLWAdlO BUILDINGELECTRICALML BINGMECHAMCAL CATEGORY CONTROLx Architect/Engineer. Llc.No: TY ELECTRICPERMIT FEE BUILDING PERMIT INFO Add PERMITISSUANCE I� ❑ ❑ LICENSED CONT CTOR'S DELLA ION �yJ I hereby affirm that l am licensed under provblom Chapter9(comsmmc APPLIANCES-RESIDE JOB DESCRB'HON�i, / ingwlthSenlon7DOO)ofMMsion3oftheBusinemand�sionsC e,and my PANELS license is In f.11fe rad effect. .fYVJYItia License xnsc Class Lir.N Date �}—CHITS or 2011000 PS y%de and ARCHITE OVERT PB SQ.FT.FLOOR AREA $/_ FT. Oren ]ufider6(a rad myphreahaR be used apubuc records �' wO SIGNSFL CAL V�j Licensed Professional �C� OWNER-BUILDER DECLARATION SPECIALCIR T/ E„ [hereby affirm that l am exempt from the Contractor's License Law for the 7.O^ following reason.(Section 7031.5,Business and professions Code:Any city or F'n9� =ntywhichmquiresaperMttocowtrucgalter, npmve,demolbh,orrepalr 1EMP.METE[4 LE[NST. 1� .� any structure prior to Its issuance,also requires the applicant for such permit to C file a signed statement that he,b licensed pursuant to the prowiors of the Contrano's License law(ChPta erg(mmmenng with Sectl"n 7000)of Divi- VALUATION w to SWBrtMING POOL ELE C O scm3 ofthe Bushussand Profenlom Code)orthat he b exempt therefemand the bash for the alleged exemption. Any violation of Section 70315 by any OUTLETS-SWITCHES-FIXTURES 666 applicant for a permit subjects the applicant to a civil penalty of no more than G five hundred doll..($500). NEW RESIDENTIAL ELECTR ❑1,as owner of the property,or my employees with wages as their sok SQJTr' 511IRIES TYPE CONSTRUCTION t compensation,will d o the work and the structure is not Intended or offered for 'S p to(Sec.7610 Busbress and Professions Code:The Comrade.Li..e Law does not apply to an owner of property,who builds or Improve thereon,and OCC.GROUP RES.UMTS E whodoes suchworkhm I lforthrough Ithownemplayees,provided thatsua Imp. :9 are not Intended oroffered forsale.If,however,thewllding or TOTAL: Improv"ment Iswldwithln oneyearofcompleti"rythe owner-wilderwlll have thg..¢'den of proving that he did not wild or Improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD'lANE APN U S as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE contractors to cere uet the prefect(Sec.7044,Business and Professions Code: The Contractor's License Law does not apply to an owner of property who Wilds or Improves thereon,and who mntram for such pWj es with a ALTER-DRAIN&VENT-WATER(EA) cq�anor(a)licensed pursuant to the Contractor's License Law. FEE SUMMARY L,J 1 am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE fU�TSI DE FEES Owner Data DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_ RECEIPT N WORKMAN COMP LIVSATION DECLARATION FIXTURES- SCHOOL TAX Y N ❑1 hereby affirm that I have a certi(Icate of consent to self-Insure,ora RECEIPT N cenificateof Workcm'Compeationls mnce ona certified copythereof(Sec. GAS EA.SYSTEM-1 ING4 OUTLETS PARK FEE Y N 3500,Iab CJ _ �i 1'oliryNm C2( GAS FA.BYSTFM-0VER4(EA) DINGRECEDIVISION - Com any15 BUILDING DIVISION FEES �Cetified here f e GREASE/INDUSI'RL WASTE INTERCEPTOR PLANCHECK FEE C y!{''ed n'PY b flied wit the city Inspection division. CERTIFICATE OFEXEMPTION FROM WORKERS' GREASETRAP PAID 1 !� COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200Fr. Date Rece1 t# (rhlssedion need not be completed lithe permit is forone hundred doll.. ($100)or few.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_ I cenifythat in the performance of thework forwhlch this permit is based, I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING a Workers'Compensation Lassa o(Call(ornla.Date PAID O Z N Applicant NEWRE9DEN ALPLMB. SQFT. Date Recei t# Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you Fshould becomrsubject to the Workers'Comperaat Ion provisions of the Labor TOTAL: W Cod,you must forthwith comply with such provisions or this permit shall be _ OO LUFEE 9 deemed CONSTRUCTIONCed. BUILDING CONSTRUCON LENDING AGENCY SEISMIC FEEE there is ion lending CL ]hereby affirm Natichthi aconstwctnued(Sec. 097,Ci C.) perform- TOTAL; ELECTRIC FEE 7 Z ance ofthe work for which this permit bbwed(Sec.309],CIv.C.) U O LeMer'a Name PLUMBING FEE LL ~ Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE OW 1tenifythat l have realthbapplication and slatethat theabove Information M Jammed.I agree to comply with all city and countyordinaems and state laws PERMIT ISSUANCE FEES PAID: >. relating tobullding construction,and hereby authobterep ativesofthb F Z city to enter upon the above-mentioned property for I I purposes. ALTERORADDTOMIKIL Date Receipt# (We)a ee to save,indemnify and arM he ty of Cupertino V AIR HANDLING UNIT(TO 10,000 CFM)agabatll Ilitles,Pcigmems,cons. n w Inanywayaccue SUBTOTAL: ag aid City in. ur.m 0 antthl rmlt. AIR HANDLING UNIT l0,000CFM) CONSTRUCTION TAX 661zSi Contra "r to EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZAR"",A . IALSDISCIASURE Will the applicant or future wild gompantstoreorlandleha>ardous HEATING UNIT(TO 100,000 BTU) Date ReceI t# material as defined by the Cupertino Municipal Code,Chapter 933 and the Health and Safety CcxIt c`l`n[-2S'32(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: ❑Yes . L7"'o Will the applicant orfmine building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE-DATE which emit hazardous air contaminants as defined by the Bay Area Air l NiiLA Quality Management D.grin BOMER.COMP MIP OR 100,000 BTU) 4Yn 1r7T U havereadthehazer ousmutctabmquirementsunderCh er6.95o[ BOR-ER-COMP(OVQtt00,000 BTU) Jl):�� 1 1 1790 the California Health&Safety Code,Sections 75505,755)7 a 34. I unde.tan hat if mebulldingdoes not mmx haves na ,thatittamy NEW RESIDENTIAL MECId. SQ.FI'. '.pont itytona#ytheompantolthesoh muMberet rIry of Cupertiuo priors ..f.Certifi.t ofO net or authorized agent to ISSUED OY: XIL Y`� TOTAL: OFFICE COPY