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20671 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY Building Project IdentificationPFILMIT NO. Building Address: jk 14-720671 0 6 7 1 3 one: G 7 G A A nera� ' CITYOFCUPERTINO-BUILDING DIVISION cono-atlnra Nam: LIc.Nn: APPLICATION /PERMIT /V �S�nR 41Z / BUILDING-ELECMCAL-PLUMBING-MECHAMCAL CATEGORY CONTROL# Arc ited/Eaginee Lk.No: QTY ELECFRICPERMIT FEE BUILDING PERMIT INFO Addicv: PERMITISSUANCE El El ❑ LICENSED CONTRACTOR'S DECLARATION I hereby affirm that[am licensed under provisions of Chapter 9(commenc- APPLIANCESRESIDENTIAL JOB DESCR11MON ingwlth Sectkm7000)of Dlvision3oflhe Busin mandPmfmkmsCode,and my license is in full fora and effect PANELS LDicenata se Cla Contractor 550AMPS i ARCHITECP DECLARATION 201-1000A.MPS ooi Professional I understand my plans shall be used u public records. OVERIODOAMPS SQ.FT.FLOOR AREA E/SQ.FF. O z�j Licensed Pro(essiol AGNS ELECTRICAL «<� N OWNER-BUILDER DECLARATION SPE)CIALCIRCUJK/MISU 1. Ihereby affirm that I.exempt fromlhe Contractor's License Law for the 70..' following reason.(Section 70115,Business and Professions Code:Any city or O'L r, TEMP.MErmb INSF. 0z cou ey,which requtres a permit to mrutrue alter,Improve,demolish,arre.1 any structure prior to its Issuance,also requires the applicant for such permit to POWER DEVICES O G O file a signed statement that he Is licensed pursuant to the provisions of the 3c: Contractor's License law(Chapter9(commencing with Section 7000)of Divi. SN, NG POO E VALUATION F• OJ sion3 ofthe Bualnessand Profess[onsCocie)orthat he is exempt therefromand Q k1 Q...5777 the basis for the alleged exemption. Any violation of Section 70313 by any OUTLE SWI FlES canc applit for a perndbubjects the applicant to a civil penalty of not more than •OO Q five hundred wec,of he Im. NEWR LEL SQ.FT. STORIES TYPECONSTRUCTION Z ❑I,as ow,will the property,or my employers with wages r their sole k_6 compenution,willdothe work andthe structure brmtintended or offered for 5 O sale(Sce.7044,Buskreu and Professions Code:The Contractors Lt..Law Ij �,1 $ does not apply to an owner of property who builds or improves thereon,and OCC.GROUPRFS.UNITS GG whoduc suchworkhirrselforthmugh hlsownemployace,provided that such improvereentsare not Intended oroffered forsale.](howevegthe building or - TOTAL: improvement bsold withinoney arofcompleriontheowner-builderwill have th�uNen of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE F DWAPN LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE contractors to construct the project(Sec.70K Business and Professions Code: The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) Wilda or improves thereon,and who contracts for such projects with a ' FEE SUMMARY - c,��t.([act (s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE U I am exempt under Sec. B& P C for this reason OUTSI UP FEE S DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y_ N_ Owner Date RECEIPTN B�� WORKMAN COMPENSATION DECLARATION SPER TRAP SCHOOL TAX Y_ N_ LfThereby affirm that 1 have a certificate of consent to u8-Insure,ora RECFIF'I'N comficateofWorkers Comperuationlmura en ora ceNfkd eopythereof(See. GAS EA.SYSEFM-1 INCA OUTLETS PARK FEE Y N Pwi38M Lab C.) RECENT# Palry#�,#!r sIa. 803 GAS FA.SYSTEMr OVER4 MAI BUILDING DI VI SION FEES cam any-�q/Oa4 Bah-- WertiBFd copy is hereby filed th the cid. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE JI CetlJied copy b filed with the city Inspection division.Y'a CERTIFICATEOFEXEMPTIONFROMWORKERV GREASETRAP PAID COMPENSATION INSURANCE SEWER.SANITARY STORMG 200FT Date Re(xi [# (This section need not be completed if the permit isfor one hundred dollars ($100)orlers.> 3YA.I.�H�.I.�tN/N ./n.EcrR ENERGY FEE Y N mce I rectify that to the per(ounof the work forwhlch this permit is issued, I shall nor employ any person in any manner so as to become subject to the rs WATER SYSTEM/TIMATING - Worke 'Comnsatio pen Uwsof Califomia.Date PAID ZZ NOTICnt NEIN RESIDFNIIAL PLMB. SQ.FT. Date Recel t# O N077CETO APPLICANT:If,Workers om e s tNfkao is Exemption,you should became subject to the Workers'Compensation provisions of the Labor TOTAL: Code,you must fort hwith comply with such provisions or this permit shall be - BUILDING FEE ,00 � ; W _ deemed revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE CL IherebyatOrmthat there ba mvtmctcut lending agency for the perform ELECTRIC FEE 7 Z ance ofthe work!or which this permit is issued(Sec.3097,Cle.C.) TOTAL: OO Lender'sN.me PLUMBING FEE F Lendcr'.Address QTY. MECHANICAL PERMIT FEE O W I certlfythzt l have madthb applicationand Aatethatthe above information MECHANICAL FEE CIL correct l agree to comply withal)city and county ordinances and Mate laws PERMIT ISSUANCE FEES PAID: >. relating to building construction,and hereby authorim representatives afthb F N city to enter upon the above-mentioned property for Wpealon purposes. ALTER ORADDTO MECH. ? (We)agree to save,indemnify an d keep harmless the City of Cupertino. Date Receipt# V against liabilities,judgment,costsand expenses hlch may In anywayacerue AIR HANDLING UNIT CFO 10,000 CfM) SUBTOTAL: age sem City in eons Iona grand this permit. AIR HANDLING UNH(OVER 10000 CFM) CONSTRUCIIONTAX _Jf/tllre Ra` Sig core of Applicant/Contractor Date EXHAUST HOOD(W/DUC'D CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or(btvre,building occupant store or handle hazardous' HE1kTINGUMT(TOI00,WOOTU) -Date Recei t# material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the - Halth and Safety Code Scct 1.25532(.)? HEATING UNIT(OVER 100,000 BM TOTAL: Yes 1iK- Willthe applicant orfuture building occupant use equipment or devices VFN'DLAHON EAN(SINGLE RESID) ISSU*CE DATE which emit hazardous air contaminants as defined by the Bay Area Air QualitY�anagement DiLiAia haBOILER-COMP PHP OR 100,=BTU) ve read the bu s materials requirenpnts under Chapler6.95 of BOILER-COMP(OVER100,000 BM / 9 the CaBfornW Health&SafetyCode,Sectlons25505,2S533 and 25534. I understand that if the building does not currently have atenant.that it bmy NEWRESIDENTIAL MECH. SQ.FT. res ponsibilitytonaifytheoccopantof there ulremenlswhichmustberrct , prio o...nceofa ific of Its nor or authonzed agent Date ISSUED By;7 TOTAL: OFFICE COPY