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19912 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY lulling AddmBuild[. Fmied ldetuficduon PKRMITNO. ra 6 - 19 912 wners amu: Phone: CITY OF CUPERTINO-BUILDING DIVISION• 'y� O c° dnr'.Na Lm.N°: APPLICATION /PERMIT t— \ " BUTLDINGELECTRICALMUMBINC-MECFNMCAL CATEGORY CONTROL M Arohited/En rer. Lk.No: QTY'`,' ELECTRIC PERMIT FEE. BUILDING PERMIT INFO Address: PERMITISSUANCE ❑ ID❑ LICENSED CONTRACTOR'S DECLARATION I hereby affirm that l am licensed under provisions ofChapter9(commenc APPLIANCFSRESIDENTIAL JOB DFSCItD'fION IngwithSe on70W)°f Divlslon3ofthe Businessand Pmfe msCodgandmy license le In frcea rad d(ed. PANQS License /m /� Date Cantrador �\� � 1.,C 4KJ ARCHITECTSDECLARATION OVER0000 AM °�.FL.FLOOR AR 8/ .Fr. µqqµ!!�20 I understand my glare.hal be used a public records. 1 `.4 E Licensed Professional SIGNS ELECTRICAL - <6 OWNER-BUILDER DECLARATION In SPECIALCTRCUIT/MTSC E, owing raffirmlhallam31.5,B fromthe Contractor's License Gw city he or countingreason.ir(Section aprmitto Business and Professions Code:Any cityorTEMP MLTER LE INYT. p� any-tythkh requires.baus to construct,uagmteh apmvent(ontlsh,or repair a any atmeture Prior to its heuance,aLsorequlresthe appllunt forsuch permit POWER DL �a V file a signed statement that he Is licensed pursuant to the provislom of the 0. Contractor's License law(Cha pler9(commencing with Section 7000)of Divi- SWIMMING E C F.,� g s�on3ofthe Business and Pna(emiovCode)orthat hsbexemptthere(romand VALUATION Q the basis for the alleged exemption. Any violation of Section 7031.5 by any // r� applicant fora permit subjects the applkant too civil pevity ofnotnnrethan ET' HF& ES 1 N` /rel �C $ fly, I,as sro nerofdeltashepr. NE Rrs ENTIA STORMS TYPE CONSTRUCTION a, ❑I,asownerof theproperty,orhe employee.otwith nwagesrthelesoleIt. JMX H rompem.7W4,wnuftesthe wwkand thea Cdurehnotlnlended License for O sae(Sec. pply to anowandf property Code:The or improves Licereelaw $$ does not ant such loanowner orpropertywho nemporlmprwvided con ,and OCC.CROUP RES,UNITS who doensuch work himseRorthwgh Maownemploycea,provided that such Improvements are not Intended oroffered for sale.If,however,lhebuiiding or TOTAL: improvement bsold withinoneyearolcompldioMtheowner-budderwlll have tlnof proving that he did not build or Improve for purpose of sale.). QTY, .,. PLUMBING PERMIT -tnFEE FLOD07ANE APN s owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE contractor,to construct the project(Sec.7066,Business and Professions Code: Tux Contndor's License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) Wilds or Improves thereon,and who contracts for such ptojede with a , +dor(q licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEESUMMARY "I am exempt under Sec, B &P C for this reason DRAINS FLOOR,ROOF,AREA,CONTI. SANITARY- Y N . Owner Date - RECEIPT R WORKMAN COMPENSATION wrifi10N DECLARATION FIXTURES PER.TRAP 501001.TAX Y N ❑I hereby affirm that I have• Insurance of consent to se8-neure,ora RECEIPT It certificate of Workers'Comperuatlonlvurance ora urtl(Ird copythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N Polity M^X(.�C.7 r20� / G T GAS EM EA.SYST -OVER6 �^) BUILDDINGING DIVISION IV VISION FEES Certified py is heed with the city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE Certified ropy h filed with the city Inspection divisors. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE 71b PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200PT Date Recel t# (Thhsection need not W mmpldud tithe permit le forone hundred dollars ($100)or less.) WATER HEATER W/VENT/ELGCIR ENERGY FEE Y N I coe codify that in the pedamnce of the work corwhich this permit is hated, I shall nm employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING Workera'Compensatlon Laws of Giltornla.Date PAID O Z Applicant Z O NOUCETO APPLICANT:If,after making this Certificate of Exemption,you NEW RFSIDENTTALPLMI,__EQTr. Date RCccl [# should become subject to the Workers'Compevmion provislom of the Labor TOTAL: Cr X� Cade,you muetfarthwlth comply with each provLsloru orlhh pemNt shall be O deemed revoked, BUILDING IL — CONSTRUCTION LENDING AGENCY SEISMIC FEE ^a IL G I hereby affirm that there h a construction lending agency for the perform~ ELECTRICFEE ZanreottheworkforwhichthbperMtlshsued(&c.3097,Civ,Q) TOTAL: 0 O lender's Name PLUMBING FEE LL 1= Lundce.Address Q'rY. MECHANICAL PERMIT FEE MECHANICAL FEE O W I cedifythat l havereadthis appliutlon and statethat theabove information bcorred.l agree to comply with all dlyand countyordlnancesand statel.wa PERMIT ISSUANCE FEES PA >. y relating to building construction,and herebyauthorize reprexntativea olthb F Z city to enter upon the above,mcntloned property for irupMe,ion purposes ALTER OR ADD TO MECH, a[e - RCCCt t# _ (We)agme to save,Indemnify an d keep harmless the City of Cupertino P seg iabilltles,Pdgmmus,costa expe seswhl maylnanywayacerue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: a Ins Id City In con sequ th gr n Is permit. AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX SI tureol Applioni cruad D e M(HAIIS'T HOOD(W/DLICT) CONSTRUCTION TAX PAID: HATARDOU ATERIALS DISCLOSURE Will the applicant or future ullding occupant store or handle hazardous HEATING UNIT(TO 100,ODO BTU) Date RCCeI t# material as defined by the Cupertino Municipal Code,Chapter 9.12,and the - Hcalthand Safety CodeSec 25532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: ❑Yet [ o Will the a ppllunt or future building occupant use equ ipment or d evices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE which emit hanrdous aft contaminants as defined by the Bay Area Air �D Quality Management Dislrid7/ BDII.FRCOMP pE1PDR t00,IX10 BTU) I—I Yrs FCL'atf 0i —havereadthehaa ous mater late requirements under Chapter 6.95 of BOILER-GDMP(QVER 100,000 B7U) the California Hoalth&Safety Code,Sections 75505,25533 and 75536.1 !1 [?7 3 990 understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECTL SQ.FT. APR res ibllitYin notify theoc p ntofthe yulrements which must be met or issusncoo(•aaQ'CertiI to I m racy. City, of Cuge[tino mer orlud age Date �� �� TOTAL: ISSUEDB OFFICE COPY