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19849 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Build in Pm'en Identification PEAUT NO. Building Address: - 1 98 4 9 a wog c� , o cancra Phb'u/one: A V p p E 2 — CITYOFCUPERTIN0.6UILDING DIVISION Contractor',Name: � L1c.No: APPLICATION /PERMIT d 4G P[� BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL# Archite /Engineer. He.N¢ QIv ELECTRIC PERMIT FEE +. BUILDING PERMIT INFO Address:' djr'( ORKT00_SvI4 Ai V*WKPPERMTISSUANCE ❑ 1:1 ❑ LICENSED CONTRACTOR'S DECLARATION I hereby affirm that l am licensed under provisions of Chapter 9(commenc. APPLIANCES RESIDENIAL JOB DESCRIPTION ingwith Sedtun7000)of hvx]nn3 ofthe Businesiand PmfessionsCode,and my license 1,in full to.and effect. PANES LicenseClass C, al�t Lich for ' Date�L�27CHITEC4 7W1� UP TO 200ANIPS AACHITECI'SD CLARATION 20I-1000 A.MIaS (a kkb1j0I5:- 0 02 I understand my plans shall be used as public records. OVERMAMPS SQ.FT.FLOOR EA $/SQ.FT. O c+z 5 Licensed Professional SIGNS ELECTRICAL 6 6 w OWNER-BUILDER DECLARATION SPECIAL CIRCNT/M I„ owing affirm that I am...( edi.e711-5,B from the ContractorsLicense Law for t he F. countingreason.i tionrmit to orumuctand Professions Code:Any city it .gipMAER OR POLI anysim which rtottspermiltocoomqui stheaprovgdemoush,or repair P � any stmcture pdortoib iuuance,ahorequlrea<heapplanl(orsu&1 =t a POWER CES c.U flue a signed statement that he is licensed pursuant to the provlsloru of the Oa� Contractor§License Law(Chapter 9(commencing with Section 7000)of Diel- SWRAM1 POOL E C VALUATION slon3 of the Businessand ProfessionsCode)orthat heir exempitherefromand Sn the basis for the alleged exemption. Any violation of Section 7031S by any OUTLE QQ El, for a permit subjects the applicant to a civil penalty of not more than a C o K five hundred della.($500). SQ STORIES TYPE CONSTRUCTION pm v. NEW RESID L ELECTR FT. ❑I,as owner of the property,or my employees with wages r offered sole , �Za compStation,wlldothe.and k.andthe structure h ct Cormended License Law O sale(Sec.apply Business and Prhfessnns Code:The or impo roes License Law 3 Q whoa not apply to an owner of property who builds or improves thereon,and OCG GROUP RES.UNITS who ovdoes mentsa notintended ntte f or dedorwgh his own e.If,ho eprovidedthatsuch improvementsarenot intendedearofc for sale.I(howevegflder the ilI haveding or TOTAL: Improvement bsold withinoneycarofcompletion,<heowner-bu0derw111 have t4CiluNen of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN LJ L as owner of the property,am exclusively contracting with licensed PERMRISSIIANCE contraction 44,to construct the project(Sec.70Business and Professions Code: The Contractor's License Law don not apply to an owner of property who ALTER-DRAIN&VEN7WATER(FA) Wilds or Improves thereon, and who contracts for such pinjin with a - FEE SUMMARY ro��B3(Tanw(s)Bansed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE LJ I am exempt under Sec B&P C for this reasonOUTSIDEFFES DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_ Owner Date RECEIPT R WORKMAN COMPENSATION DECLARATION FIXTURESPERTRAP SCI;OOLTAX Y_ N_ ❑I hereby affirm that I have a certfiate of consent to self-inwre,or a ✓. REC=a ofrtlRateo(Workem'Compematlon Insurance or a certified copythereof(Sec, GASEA. INC0UTLETS PARK= Y N 350Q Lab C.) S .4 RECEIPT N PolicyX GAS PA.SYSTEh1-0VER 4(FA) Cany BUILDING DIVISION FEESomECertlOed copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE �y I Certified copy b filed with the city inspection division. II`Y CERTIFICATE OF EKEA4PTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM FA.2(DFT. Date RCCCI [# (Thi,section need nor be completed tithe permit isforone hundred dollars (SIM)of less.) WATER HEATER w/VENT/ELECTR ENERGYFEE Y N I permit that In the performance of the work forwhich this pewt is issued, , I shall not employ any person In any manner an as to become subject to the WATER SYSTEM/TREATING Workers'Comns peation Lawsof California. Date PAID 0 Z, Applicant NEW RESIDFNI3AL PLMB. SQFI'. Date RCtt'I [# Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should become subject to the Wurkeri Compensation provisions of the Labor TOTAL: fq Code,you most forthwith comply with such provisions or this permit shall be BUILDING FEE LU G deemed revoked. CL CONSTRUCTION LENDING AGENCY SEISMIC FEE I hembyaffirmthat there u a construction lendingagency forthe perform TOTAL: ELECTRIC FEE M 0 arse of the work for which this permit is issued(See.3097,CIv.C.) — IenderaNaPLUMBING FEE LL LL me Lenders Adarersa Cr QTY. MECHANICAL PERMIT . FEE O W. rt l aditythat l havemabb"applialionand,fate thattbeabove Information MECHANICAL FEE a iscor .I agree to comply with all dtyand county ordinances and state laws PERMIT ISSUANCE FEES PAID: >_ N relating to building construction,and hereby authorise representatives of this F city to enter upon the above-mentlord property for inspection purposes. ALTER OR ADDTO MECH. ? (We)agree to save indemnify an d keep harrnlese the City of Cupertino Date Receipt# L.I against liabllltlas,%adgments,cossand npenxswhlch mayln anywayaccrue AIR HANDLING UNIT CTO 10,000 CFM) SUBTOTAL: against,aid City,in conaryuene,of the granting of this permit w//�, AIR HANDLING UMT(OVER 10,O00 CFM) CONSTRUCTION TAX Signature of nppliant7tZont.nor ~— s Exruusr HOOD(w/DUCI) - CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous HEA TING UNIT(TO 100,00)BTU) Date Recei t# material as defined by the Cupertino Municipal Code,Chapter 9.1;and the Health and Safety cme,Synion 2s531(a)7 HEATING UNIT(OVER Iffy"BTU) - TOTAL: a El Yao1A No Willtheapplica tune building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) �[ CE DATE which emlt hazardous air coreamimnts as defined by the Bay Area Air �MF�6ja� Quality Management District? BOILER-COMP OHP OR 100,IX0 BTU) 4YNo havcn read the Faa�usmaterials requlmmentsunder Chapter 6.95of BORER-COMP(OVER IOO,OWBTU) 199Uthe GThfmia Health&Safety Code,Sen Ions 25505,25533 and 25534.1 f 1 u ndersta rad that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.ET. rnponsibility to notify the oreepant of the requirements which must be met fst�ra sat prior to issuance of refiat lOmpanry. - #111' sN -r -�3-� Owner or authorized age � Date TOTAL: OFFICE COPY