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2879 (2) APPLICANT TO-FILL IN INFORMATION WITHIN RED LINES —'USE BALL POINT PEN ONLY Building Project Identification ewlamg ndaresa:Z e,% 22879 ekstwnere ams: o • q - CITYOFCUPERTINO-6UILDINGbIVISION ctntradnr'.Name: Lie.Me: APPLICATION /. PERMIT-. Q'1 - " BUILDING-ELECTRICADPLUMBINGMECFIAMCAL CATEGORY , CONTROL# Architect/Engines Lk.Nee - { �'�t ,.i +••t`r .,t At gyp . . -t .aI'i iBUILD�NG,�ERM1;P,INFQ"p-` , n , ELECTRIGPERMIT �FCB - R Address: PERMIITISSUANCE - LICENSED CONTRA TO �• l® C R S DECLARATION - - mtlnl -fC9nc- APPLIANCES-RESIDENTIAL - JOB DESCRIPTION license Isle tial faceend effect. PANELS . 1 '� License Class Lk.p _ `1 W� Date ContractorUPT0200AWS - - ARCHITECIPSDECLARATION - ' 2011000 AMPS K Z I understand m Elam shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FC: 00 YP w SIGNSELECTRICAL' VLicensed Profeastunsl _ .. 6 OWNEReBUILDER DECLARATION iii�Ii3 SPECIAL CIRCUIT/MISG - p„ Iwing atter.(Sectlam31.5,Business he sad PrefdorbiCode:ense Law fort he - ' =ntywhichequims(Section7031.5,euslnessand Plinp ve e=re hnycity or TEmp,METERORPOLEINST.- ' ctuntywhah rryutresa permlttoconstrud alt improve,demolbh,orrcpalr ' g`'B anystrocture prior to its Issuance,also requires the applicant for such permit to POWER DEVICES ilk a signed statement that he Is licensed pursuant to the provisions of the ' 3w Contradoes License Law(Chapter 9(commencing with Section 7000)of Divi- VALUATION• O slonli oflhe Business and Profemlom Code)orthat he is exempt therefrom and SWIMMING IDOL ELECTRIC O 5 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLEISSWITCHESEXTURES applicant for a permit subjects the applicant to a civil penalty m of not ore than �] 'five hundred doll..($500). ��, RG" NEW RESIDENTIAL ELECTR - .STORIES TYPE CONSTRUCTION ..p, ❑I,as owner of the property,or my employees with wager r[herr sole compensation,Business Work,aedtheslmdureh not Intended oroffered for ' sale(Sec. pply to an df property Code:The Contraorimprves License Lawdoes rj$ whodotapply torn owner ofthroug hiswho builds orimproovided thereon,and c• who daesauchwork himself orlhrough hlsownemployees,provided that such OCC.GROUP RIS.IINCCS Improvements are not intended oroffered far sale.If,however,the building or 'TOTAL: Improvementlssoldwithin oneyearofcompldrogtheowner-bu8derwili have , - t rden of proving that he did not build orimProve acting wfi.!site se f,JTY: ) PLUIvIBING.EBRMITt- F[gpD ZANE APN as owner of the property,am exclusively contracting with.11censed pgp�fIT ISSUANCE f co radon to cons the project(Sec.7044,Bursas and Pmfesvioru Code The Comrsdore License IJw doe.ani pply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) Wilda or Improver thereon,and who neram . for such P"cis with a a y, 1 i ' myt{actor(s)Iicensed pursuant to the Contrador'e Lkenee Law. v "'FEE'$UMMARY'("' I am exempt under Sec .B&P C for this reason BACKFLOW PROTECT.DEVICE OUTS]DE FEES SANITARY Y N Owner - Date - - _ DRAINS FLOOR BOOP,AREA,COND. - WORKMANCOMPENSATION DECLARATION RECEIPT#pp(TURES PER TRAP - SCHOOL TAX Y_ N_ ❑I hereby affirm that I have.emat(o lmurcese of consent to opy tneneo ora RECEIPT i ce00,La eC.Workers'Compensatlonlnsurance ora certified ropythereof(Sec. , GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE ,Y_ N , 3glic Lab C.) I'ollry p GAS F.A.SYSTEM-OVER 4(EA) RECEI'C# Com any ' BUILDING DIVISION FRES ffCenlfledropybhembyfurnished, CREASE/INDUSCRL WASTE INTERCEPTOR PLANCIiECK FEE .❑Certified ropy k filed with the city inspectlon db l.lon.' CERTIFICATE OF FSFMPCION FROM WORKERS' - CREASETRAP - PAID COMPENSATION INSURANCESEWER-SANITARY-STORM EA.200FT. -Date Remi t# ' (rhissection need not be completed lithe permit isfor one hundred dollars ($100)orlew.) 7 WATER HEATER W/VENT/ELFCTR ENERGYFEE Y N. I unify that in the performance of the work for which this permit is tisued, I shall not employ any person in any counter so ae to become subject to the WATER SYSTEM/TREATING Worken'Compeneationl wsof Califomla.Date PAID ' O Z Applicant - NEW RESIDENTIAL PLMB. SQFT. Date Remi t# ` Z O NOTICE TO APPLICANT:[(,after making this Cedl(Icate of Exemption,you ,F should become subject to the Workers Compensation Prwisimuo(the Labor •- -TOTAL: N Code,you=at forthwith comply with such provlsiow or this permit shall be - W G deemed revoked. . - . - BUILDINGFEE 1CONSTRUCTION LENDING AGENCY SEISMIC FEE I hereby affirm that there Is a construction lending agency for the perform ELECTRIC 7 Z ance ofthework forwhlchthfe permit lC leaned(SL ec.3097,Civ.C.) TOTAL: ` ()O' fenders Name - - 3 �, PLUMBING FEE ly F Lenders Address QTY. " .MECHANICAGPERMIT [FEE' MECHANICAL FEE OW I certify thatl have readthis application and statethatthe above Information - ,a is correct.l agree to comply with all city and county ordinances and nate laws PERMIT ISSUANCE FEES PAID: , } relating to Wilding construction,and hereby authorise representatives of this - H Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. Date Relies t# (We)agree to save,Indemnify an d keep harmless the City of Cupertino P against liabilities,I.dgmenls,consand expense.which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: against said Cl consequencamthegramingofthl ermit ., /40. - A[R HANDLING UM T(0VERI0,(F0CFM) CONSTRUCTION TAX. ' Igna mr pp ant/ omractor Date G EXHAUST HOOD(W/DUCT) - - CONSTRUCTION TAX PAID: HAZARDOUS ERIALS DISCLOSURE ' . ' Will the applicant or(uture building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)' Dale PRfCeI t# material 5s defined by the Cupertino Municipal Code,Chapter 9.12,and the Ikalth and Safety Code Section 2S532(a)?' HEATING UMT(OVFS 100,000 6TLB 'TOTAL: Ye. M No Will the applicant or future buildimi'mcupant use equipment or devices VENTILATION PAN(5INGLE RESID) - ISSUANCE DATE m. which emit hazardous air coma minants as defined by the Bay Area Air - Quality Management District? BOILER-COMP OHPOR 100,000 BTR) n❑Yes ❑No /f �' r Ihavc read the hazard. maicrials requlretnents under Chapler6.95 of BOILER-COMP(OVER 100,003 BTU) the California Health&Safety Code,Sections 25505,25533 and 25534.,1 understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MF.CH. SQ.FF - Jg respoosibiity to notify the occupant of the requirements which at be met .\ prior to issuance of a Certificate of Occupancy, v� Owner or authonzed agent - Date" ISSUED BY ' TOTAL: OFFICE COPY