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21102 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY k „-r- Z - Building Project Identification S Building AddrosE C Y � l l PERMIT re ams: p K M—LP1NL G-Q©u 1 ITY OF CUPERTINOLBUILDING DIVISION APPLICATION /PERMIT UILDINC-MFCTRICALPLUMBING-MECHANICAL p L\v T • C CATEGORY CONTROL. N flF ELECTRICPERMIT FGEAddress BUILDING PERMIT INFO I77SSUANCE Q7 ILICENSED r[JIherchyeffirmthat CONTRACTOR'S DECLARATION l amlicensed under provWons ofChapter 9ANCESRESIDENf1AL Ingwith Section7W0)of Divlston3 ofthe BuslnessandP esalonsCode,and my it I I fUI1&r2Wdoffed-' Lice C Iff c JOB DESCRIPTION s FDw l-. PM Date'_ CLontractor hTS . 2011000 AMPS ARCHITECTS D LARATION I understand my plans shall be used u public records Licensed Professional OVERIODOAMPS e.R�(�hT� FLOOR AIIFA $/�� SIGNSELECTRICAL . OWNER -BUILDER DECLARATION I herebyaffirmthat l am exempt from the Contractor's License Law for the 0 q17 nJ- ^ �1 V SPECIALCIRCUIT/MI9C TEMP. METER OR POLE INST. following reason.(5edion 7031.5, Business and Prefealum, Code: Any city or county which requires a permit to ronstmd, alter, Improve, demolish, or repair any structure prior to Its issuance, also requires the applicant for such permit to a signed statement that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9(commencing with Section 7000) of DIA- cion 3 ofthe Bustneeaand PrefeuloneCode) orthat he Is exempt thercfromand the bash for the alleged exemption. Any violation of Suction 7031.5 by any appBant for a permit subjects the applicant to a civil penalty of not morethan five hundred1, as hepr. I, as owner of the properly, or my employees with wages thele dole EERIER DEVICES SWIMMING POOL ELECTRIC OUTLETSSWITCHFSFIXTURFS ARID , NEW RESIDENTIA FQ.Fr. STORIES TYPECONSTRUCTION Oa I bo r d for compensation, 704 Busso the ess and rk, and the dtrudure 13 he ot Con ended License sale (Sec. 7066, Business and Profeulons Cade: The Contndors Llrnnse law Law TOTAL I b does not apply to an owner of property who builds or improves thereoq and whodoes such work bimselforthrough his own employees, provided that such m Improveents are not Intended or offered for sale. If, however, the building or Improvement issold within oneyearofoomplHlon, theowner-builderwill have WC.GROUP RES. UNITS tha*rden of proving that he did not build or Improve for purpose ofule.). LJ L as owner of the property, °m exclusively contracting with licensed contractors to constthe pmjed (Sec 7014, Business and Professions Code: QTY. PLUMBING PERMIT PERMIT ISSUANCE1 FEE ^t L 1 FLACCID ZONE APN The Conmomra License Law does net apply to an owner of property who builds or Improves thereon, and who contracts for such projects with on darts) licensed pursuant to the Contractors License Law. I am exempt under Sec B 6a P C for this reason ALTER -DRAIN &VENT -WATER (EA) s� FEE SUMMARY BACK FLOW PROTECT. DEVICE FrFq DRAINS FLOOR ROOF, AREA, COND, FD(TURFS PER TRAP NI SATARY Y N— RECEIPT N Owner Dale M WORK AN COMPENSATION DECLARATION ❑I hereby affirm that I have to SCHOOLTAX Y N c of consent ocertificateInsurance thxrc, ora adi0ceteofWarkere Compensation lruunnceorarndlfkd RECEIPT N CAS- EA. SYSfEM1 INCE OUTLEI5 PARKFEE Y—N ropythereo((Sec. copy 380q labCJ Polity M RFC®T N Com any GAS EA. SYSIE➢H-OVER d (EA) BUILDING DIVISION FRES MCedlfled copy is hereby tumts city �Ccrilfled ropy b flied with the cisty inspection division.111/... GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEC- to GREASETRAP CERTIFICATE OF EXEMPTION FROM WOR KERS' COMPENSATION INSURANCE (Thbeectisn need not becompleted lithe permit V fororie hundred dollen PAID .ne Date Recel t# Ss SEWER -SANITARY -STORM EA. 2007tFr (s100)orlyth Irndlfythat In the performance o(the work forwNch this permit Is blued, I shall not employ any person in any manner an u to become subject to the Workers' Compensation Laws of Cattfornla. Date WAFER I{EA /VENT ECTRENERGY FEE Y N — WATER Sys )&/ T�PAID Applicant NOTICEco APPLICANT: a after kinre'Co this ation Certificate of Exemption tans should became evbjactmthe Workers Compensation provblotu ofthe Labor comply with such provBlons orlhb permit shall be deemed revoked. Recet tp NEWR ENTIAL gDate T ALCode,you=atforthwith BU CONSTRUCTION LENDING AGENCY I herebyalfirmthal there is a construction lending agency for the perfarm and of the work for which this permit is based (Sec. 3097, Civ. C.) Lenders Name Lendur§Addres, I cod ify that I have read this application and state that the above Information ts cornet. Iagrre to comply with all dtyand county ordinances and orate laws relating to building construction, and hereby authorize representative, ofthi, city tuenter upon the above-mentioned property for Inspection Purposes. (We) agree to save, Indemnify an d keep harmless the City of Cupertino TOT U as��A t V SEISMIC FEE ELECTRIC FEE QTY. ECHA ICAL PERMIT FEE PLUMBING FEE MECHANICAL FE O PERMIT ISSUANCE eta QJ FEESPAID: n i —E —LL - ALTERORADDTDMFCH. nanywayaccrue agalrut llablltl gntee!55� 1,000CFM) O Z AREIANDLINGUNIT(TO10,OD0CFM)AL102lnsnsiL AIR HANDLING UNIT (OVER IO.00 Igutureo A a /Contra or Dat EXHAUST HOOD(W/DUCT) Al 86 MDateRmei HAZARDOUS MATERIALS DISCLOSURE D - HEATING UNIT (TO 100,ODO BTU) Will the applicant or future building occupant atom or handle hazardous outerfalasdefinedbythe Cupertino Munldpal Code,Chapter9.iZandthIt E1calthand5fny Code Sactlon25537(a)'f ❑ Yea r] No t HEATING UNIT (OVER 100,D00 BTU)A : VENTILATION PAN (SINGLE RESID) ISSUANCE DATE ��® AER 1 1991 Will the applicant on future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management DBtrid7 4 Yes o oNo have read thehaza materials requirements under Chapter 6.95 of the California Health 4 SafetyCode, Sections 25505,25533 and 25536.] indents rad that if the building doe° not currently have a tenant, that It is my responsibility to notify the occvpant o(the rcqulrcmenis which must be nmt BOILER -COMP OHP OR f 00,DM BTU) BOILER-COMP(OVE3100,000 BTU) NEW RESIDENTIAL MECH. SQ.FT. LIqt priorto Issuance of a Certificate ofOceopanry. /."in City"Mg ISSUEDBYV :C.1�1 Owner or authorized agent UTOTALate TOTAL: OFFICE COPY