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23043 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PERMIT NO. Building Address: - WOW 23043 rs came: e: A A A jf CITY OF CUPERTINO-BUILDING DIVISION Cw et Name' /_� APPLICATION /PERMIT VII `�� BUILDING-ELECTIICAL-PLUMBING-MECkNMCAL CATEGORY CONTROL Architect/Engineer. Lic.No: QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO Address: PFRM[HISSUANCE El ❑ ❑ L 6 LICENSED CONTRACTOR'S DECLARATION L� s. I hereby afxrr70W) l Nisi n.sedunderprovtdmn,of Chapter9(comment APPLIANCESRESIDENI'IAL JOB DESCRIPTION ingweh5etlon 7f100)of DlWMon3 of he Buslncua dPro(eulonsCode,and my license isles nall_ryrpq up erren--�5� � PANELS LicenseC a4.�! lam'. _LIc.N L Date Contractor ARCHITECTS OEC ATION 201-1000 AMI5 q�u M, ]understand plawaluRbeuseclaspublicrecoards. OVERIWAMPS SQ.IT.FLOOR AREA S/SQ.FT. 6r.Z E Licensed Professional SIGNS ELECTRICAL In n N ALE D 1 Q OWNER-BUILDER DECLARATION G, Fit SPECIALMETER KM MPU E R k, y Iherebyaffirmthat Tam exempt from the Contractors License Law for the 0 f. following recon.(Section 7031.5,Business and Professions Code:Any Sty or Tpdp METER OR POLE ST. countywhich requires a permit to construct,alter,Improve,dennlbh,or repair anystrocture priarto its tuuance,also requiresthe applicant for such permit to POWER DEVICES / / L file a signed statement that he is heensed pursuant to the provisioru of the !! G.a OreContracto/s License Law(Chapter 9(mhm (commencing with Section 7000)of Divi- gwil NG ELECTRIC 30rn sion3 ofthe Businessand Pmfenioru Codc)orthat he is exam tleerefromand VALUATION ,fir.a the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS HES-FIXTURES applicant fora permit subjectsthe applicant to a civil penalty of nM more than liv-11,hundred owner of the pro NEW R ENDAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION ..�n ❑Las owner 1 the property,or my employees with wage as their sok G>a compemation,willdothe work andtheMrocture is not ntended or offered for $�O rile(Sec.7044,Bu,ine„and Professions Code:The Conlractols Licerue law $g does not apply to an ownerof pmperty who Wilda or lmprons thereoryand OCCGROUP RIS.UMTS who does such work honselfortheaugh his own employees,provided that such improvements are not Intended or offered for sale.If,however,the building or TOTAL: Improvement issold within one yea rofcompletion,the owner-builderwill have t4jS urdcn of proving that he did not Wild or improve for purpose of sab.). QTY. PLUMBING PERMIT FEE FLOOD LONE APN Lj L as owner of the property,am exclusively contracting with licensed PFRh1I.1.ISSUANCE contractor to construct the project(Sec.7044,Business and Professions Code: The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN kVENT-WATER[FA) Wilda or improves thereon, and who contracts for such p4ajects with a FEE SUMMARY cott dor(s)bcenwdpunuantwthe Contactor'.License Law. BACK FLOW PROTECT.DEVICE LJ I am exempt under Sec B h P C for this reason DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N� � Owner DMe RECEIPT N WORKMAN COMPENSATION DECLARATION FIXTURES—PER TRAP SCHOOL TAX Y_ N_ [-]I herebyaf(Irm that I have a certificate of consent to cal(-Neure,ora RECEIPT N mrti/irateof W.rkersCo�pensaif. once ora certifiedoopythercof(Sce. GAS EA.SYSTEM-1 WC4 OUTLETS PARKFEE Y N 3800,lab C. 11'!1!C/ Z� RECEPT# Policy# WLII�� GAS EA.SYSTEM.OVER 4(EA) BUILDING DI VIS ION FF.ES Com any �C fled copy is hereby ished. GREASE/INDUSTRL W EPTOR PLANCHECK FEE chified copy b filed with the city W pe Sion division. CERTIFICATE OF EXEMPTION MOM WORKERS' GREASETRAP PAID COMPENSATION INSURANCE SEWER-SANITARY RM EA.2e0FT. Date Recti t# (This section need nes be completed if the permit is for one hundred dollars ($100)or lova.) WATER HEA W/VENT/ELLCTR ENERGY FEE Y_ N_ 1 certify that in the performance of the work for which this permit is Issued, I shall not employ any person in any manner so as to became subject to the WATER /TREATING Workers Compensation Laws or California. Date PAID Z Z NOTICE TO APPLICAlicant M:It,after making this Certificate of Exemption,you NLVd DENIAL PLMB. SQ.FT. Dale Recei [# P: O should become subject to the Workers Compereation provisions of the labor TOTAL: �) Code,you most forthwith comply with such provisions or this permit shall be BUILDING FEE j deemed revoked.LU — CONSTRUCTION LENDING AGENCY SEISMIC FEE 1 0 Thereby affirm that there is a construction lending agency for the perform- ELECTRIC FEE 7 Z ante of the work for whim this permit is issued(Sec.3097,Civ.C.) TOTAL: 00 Lender's Name PLUMBING FEE LL I- Lendn.Addrcss QrY. MECHANICAL PERMIT FEE MECHANICAL FEE O W a isco ces 1certl/ythat l have read thisapplicaun and aatethat theaboveleformation /p 1 ed.iagene to comply wlthall city and countyordlnanand state law, PERMIT ISSUANCE /�I FEES PAID: >. 9L to building construction,and hercbyauthodu representativesof this F N city to enter upon the abovo-mentioned property for inspection purposes. ALTER OR ADD TO MUCH. Z (We)ogre to save,Indemnify an d keep harmless the City r Cu ea[ Date Receipt# V against llabl tea ' gmenta,costa and expenses whichmaylean wa accroe AIRHANDLINCUNITO0I0,0X)CFM) SUBTOTAL: agalrat sal Cty aequenceo egrarti fiat thio pe it. I ' AIR Hwnvulvc lmTr roVER 1o,BBBCEaf) CONSTRUCTIONTAX Signature of Applicant/Contractor Date EXHAUEiT HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous ' I rEATING UNIT(TO 100,000 BN) ( Date ReceI t# material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the - \ Health and Safety Cade Section 25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTA ❑Ye, No Will the applicant Aure Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE I which emit hazardous air contaminants as defined by the Bay Area Air Quality Management DlMdct] BOILER-COMP O)NOR 100,000 BTU) PAI P9 '?have Yo Na read the haaarclo..maleriais requirements underCM1aptcr 6.95 of BOILER-COMP(OV1R 100,000BN) the California Health k Safety Code,Sections 25505,25S33 and 25534.I understand that lithe Wilding don not currently have a tenant,that it is my NEW RESIDIENTIAL MECH. SQ.FT DEC17 19 responsibility to notify the occupant of the requirements which must be met prior to Issuance o!a Certificate of Occupancy. GI I), uF gulp U Owner or authorized agent Date ISSUED BY: TOTAL: OFFICE COPY j ,