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19675 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE SALL POINT PEN ONLY Building Project Identification PIRMITNO. Building Address: Phone 1 9675_ Q a iter. . CITY OF CUPERTINO4BUILDING DIVISION G lranorsName: M Lm.No: APPLICATION / PERMIT d L '•aCATEGORY CONTROLM ( Architect/Engineer. Lle No: BUILDING-ELECTRICAI.PLUMBINGMECHAMCAL QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: PERMITISSUANCE ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION I hemisyaffman that l am Bcensed under provisions of Chapter9(comment. APPLIANCES-RESIDENTIAL - JOB DESCRITIDN Ingwlth Sectlon7IXp)of DiAslon3ofthe BuMi and PmfesslonsCode,andm lire..Is In fit ( rce d effect. PANELS LIcen.Cla. LIc.N Z S �� Dal .Contractor p ARCHITECTS DECLARATION 201-1000AMP5 I understand rrry plana shallbe used as public records. OVER 1000 AMPS ( SQ.FT.FLOOR AREA /SQ.Fr. Ett Licensed Professional SIGNS ELECTRISAZS 05 <Q, OWNER-BUILDER DECLARATION to a t. I hereby afRrm that I am exempt fromthe Contractor's License Lw for the SPECIAL CIRCUIT/ 7 pp following reason.(Section 7811.5,Business and Professions Code:Any city or O Z F TEMP.METIR NST. K, CAY F) 4 countywhkh rcquircse permit lomnstrun,alter, demolish,or repair , 4 anystmmmpriortoltslmance,alsorequlmlheappllantforsuchperMtto POWER DEW P O file a signed statement that he V Ilce.sed pursuant to the provbios of the Q6 O� Contractors License Law RClupterl fica—ndngwlth Section Met).(Divi- kwiMMING ELEC7WC Lh aten3olthe Beelneeand Pm(esslos Code)orthat helse.mpttherefromand VALUATION Q the basis for the alleged exemption. Any violation of Section 70315 by any applicant fare permit subjects the appBcant to a nvll penalty of notmorethan O E'IS H ES five hundred dollars($500). NE TNT[ L SQTT. STORIES (O TYPECONSIRUCTION �n F11,as owner of the property,or my employees with wages as their sole OPCC compe.sallon,willdothn work and theetsnurels not Intended or offered for Q .1.(Sec7044,Buai..sandPmfevlos Ccde:The Contractors License Lw h/i $ does not apply to an owner of property who build,or Improves thtmo,and RFS.UNITSOCC.GROIJIa EE who does such work himself or through his own employees,provided that such _ improvements are not Intended oroffered forsale.If,however,lhe bulldingor TOTAL: Improvement lssold wlthlnoneyearofcompletiorylhe owner-builderwlll have Iti„kurdenof proving that he did not build or Improve for purpose olsale.). QTY, PLUMBING PERMIT FEE UL as owner of the property,am exclusively mntratting with licensed FT-OOD ACNE APN contractors to construct the project(Sec.7064,Business and Professlos Code: PERMIT ISSUANCE Ile Contractor's License Lw does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(PA) Wilds or Improves thereon, and who contracts far such pkajoes with ott nor(s)h...d pursuant to the Contnnore Lice..Lw. BACK FLOW PROTECT.DEVICE FEE SUMMARY 1_,j I am exempt under Sec. B&P C for thin recta.. DRAINS.FLOOR,ROOF,AREA,COND. SANITARY Y . N Owner Date RECEIPT N WORKMANCOMPFNSATIONDECLARATION FIXNRES PER TRAP SCHOOLTAX Y_ N ❑I hereby affirm that I have a cartiBctte of consent to self-Insure,ora RECER'r N cerufiate ofWorkera'Compesatlonlsurance or a certified copy thereof(Sec. GAS EA.SYSTEM-11NCAOUTLETS PARK r•Ee RECEmr If Go1iryN GAS.EA.SYSTEM-OOVER FA Com ( ) BUILDING DIVISION FEES �Certil(edc py is bercbyth the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE F-1 Certified copy V(fled with the city Inspection division. CERTIFICATE OF EXEMPT ION FROM WORKERS' GRFASE TRAP PAID- COMPENSATION INermit for SEWER-SANITARY-STORM EA.200FT. Date Recal tic s section need not W completed Rp the permit E(oras hundred dollars (S100)orless) WATERHEATFRW/VENT/ELFCTR ENERGYFEE Y N Icertlfy thatlothe penormance of the work forwhkhthis permit bbsued, I ahall not employ any pawn In any manner so as to berone subject to the WATER SYSTEM/TREATING Workers Compensation Lim of California. Date PAID ZZ Applicant NEW RESIDENTIAL PLMB._SQ.Fr. Date Recet tit O NOTICE TO APPLICANT-.IL making lhla Certificate of Exemption,you should become subject to the Workers CompesatWn proWlos of the Labor TOTAL: W Code,you enst forthwith comply with such provbios.rthb permit shall he BUILDING 7- 0. V W j deemed revoked, a c CONSTRUCTION omtmdlLENDINGen AGENCY SEISMIC FEE O (hereby afRrm Mut then Raconstmnlonlending agency 7,Civ. ted perform ELECTRIC FEE L) Z aendersthe work forwhkhthb permit Vi.A,ed(Sec.3097,CIv.C.) TOTAL: U O lenders Name PLUMBING FEE LL Q LenaersnahatI Q'rY. '. MECHANICAL PERMIT FEE MECHANICAL FEE O LU Treed.I agree havemad mply with allcitll ynand dcounterhattheyordina aboveinformation IL hcoingt lagmto complytio,andherbyauthyoa,representatives gatelawsPERMTTISSUANCE FEES PAID,. } W relating to building costsnlory and hereby authorize repre.ntativcs of thin H Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECFL Date RecCi t>< _ (We)agree to save,Indemnify an d keep harmless the City of Cupertino P against liabilities,jedgmenfs,msteand expenses which may lnanymyaccme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL• ..S g��ai--TsTt said City In copse ce of a granti of thl.proadt. �1et 2. y{�s AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX oaturc of ppEe,mt/C traitor Date EXHAus'r HooD(W/DUCT) ' CONSTRUCTION TAX PAID: HAlAR DOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCYCI I# material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the Health and Safety Cade SlUNIT2S532(a)7 HEATING UT(OVER 100,000 BTU) TOTAL: ❑Yes �en- Will the applicant orfuture building occupant use equipment ordevices VENTILATION FAN(SINGLE RERD) ISSIlM1_ DATE which emit hazardous air rontarrdeants as defined by the Bay Arca Air Quality Management UlaMn7 BOILER-COMP OFE'OR 100,000 BTU) I 4Yf9 O vJJ h.ec mdthe haze osmuferiats requiremenfsunderChapterg.95 o! BOILER-COMP(OVQR 100,000 BTU) the California Health&Safety Code,Sections 25505,25S33 and 25534. I understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.Fr. responsibility to notify the occupant of the requirements which must be CaItV O} (SII^rtrtlBD prior to issuance a a Cert fl o c-P ry. t, nerorauthorimp Date ISSUEU BY: �� TOTAL: OFFICE COPY