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23704 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY B.Bdi.1 Project Idemlfl,aah. - PFRMITNO. Building Address: 23704I ams: a one: / �ZUe� L'Z3� CITY OF CUPHRTTN0.BUILfl1 ]VISIONp � con actoYs Name:�� 1 AFFLICA IION SUBMITTAL DATE APPLICATION / MIT J � BUILDING-ELECTRICAGI'L BI -MECHA CAL CATEGORY CO [R Afchite /En neer: Llc.No: ,QTY ELECTRIF,,FEjmrr FEE BUILDING PERMIT INFO Addreace PERNUTISSUANCEK LICENSED CONTRACTOR'S DECLARATION I herebyafflmn that l amllcensed under provisions of Chapter9(romerene APPLIANCES 1, OB DESCRITM N Ingwhh SeMon7000)of DivlsIon3of Bu.Irq Rpd Professions Code,and my license is in full fore iced effect. / P Lirense.CU LILY Date t _Contractor 20 PS T ARCHITECI'g DECLARATION "v gflq�vz I rstandmy plaru.)sell be used upublic records V 1 AMPS �.bT.FW�5AREA $/ � Fi Licensed Professional SI S ELEC C JJJJ,/tvsaJ� .5 G�6 OWNER-BUILDER DECLARATION SPEC LCIR T Y 7 I herebyafflrmlhatlam exemptfromlhe Cenlractor's License lewfmthe following resson.(Scetlon 70915,Business and Professions Code:An dyer F ti� countywhich requires a permltmcorutruct,alter,ireprove;dernalbh,Any P.M LEINST. 'y anystmaure pdorm its bsuence,aborcqulreathe appliont(or sucM1 permitto \e file a signed statement that he b licensed pursuant to the provisions of the ]'OWER DEV] 7� Oµ Contractor's License Law(Chapter 9(mrmrendng with Section 7000)of Divi- �0� slon3 ofthe Business and Professbve Code)orthat he b exempttherefmmand SWBd?A NG ELECTRIC VALUATION the basic for the alleged exemption. Any violation of Section 70HS by any UTLETSSWITCFIFSHX'HJRES Z{//1 1 O applicant(ora permit subjects the applicant to a civil penalty of net more than aC`T.Ca-JI Eye hundred dollars(5.5001. NEW RE4DENIIAL ELECTR �^�n ❑1,as owner of the property,or my employees with wages as their sole S'FT' (?RIES TYPE CONSTRUCTION compenmtion,will do the work,and thestructure is net intended or offered for i17 Osale(See.7099,Business and Professions Code:The Contractors License Law C does net apply to an owner of property who Wilds or improves thereon,and OCC.GROT>It\ UNITS who does such work himself orthrough his own employees,provided that such \ • Impmvemenb am not Intended oro(fered for sale.If,howevepthebulldingor TO � Improvement 1=1d within oneyearo(comple io4theowner-WBderwlll have IFaj2urdnn of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD70NE APN 11 S as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE contractors to construct the project(Sec 7W44 Buslnem and Professions Code: The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT WATQt(FA) Wilds or Imve prothereon,and who manatees - - s for such ptojects with a r� rynjTactor(s)Bernard pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY LJ I am exempt under Set B&P C for this masonOUTSIDE FE-ES Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N RECFLTY WORKMAN COMPENSATION DECLARATION pttTURF$PER TRAP SCHOOLTAX Y N_ r©I he affirm that I have a certificate of consent to eel(-Insure,or a RFLETPf Y 3800,L.b C.) S GW ceniiesterd Workers Compemnionlmuranreoracertlfled ropythereo((Sea GAS. GMa FEE FEE Y N Policy M GAS FA.SYSTEMAVER a(En) RECEIPT N Cny BUILDING DIV ION FEES Ereni(led copy b Bled ereby the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKF r/ ❑rectified copy b heed with the city inspection division. �O CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM FA 2001r1,. at Recci _+ (fhbeection need not to completed If the permit bfor one hundred dollars ($100)oify that WATER HEATER W/VENT/ELECTR E - •E �11y I ll nor that o the performance of any he manner so as to b co permit c Issued, �J(/vf)A I shall not employ any person in any manner so az to become subject to the WATERSYSTEM/TREATING Workers'Compenaatlon lAwe o(Ca Bfomla.Date PAID 4 Ca O Z Applicant NEWRESIDENTIALPLMB, SQ.FT. DRte ea,- t# Z O NOTICETO APPLICANT;If,after making this Certificate of Exemption,you should become subject to the Worker Coceperuatlun provbloro of the Labor T TAL: N Code,youmustfonhwithcomp)ywltheuchpmWsioroorthisp.n tshallbe ` Uj j deemed revoked. _ B "E aO CONSTRUCTION LENDING AGENCY SEISMIC FEE I hereby affirm that there is a construction lending agency forthe perforce, ELECTRI 7 0 anre of the work for which this permit b Issued(Sec.3D97,CIv.C,) T �� V fender's Name PLUMBI E --�� LL I— Iender.Addree. QTY. MECHANICAL PERMIT FEE MEC LFE' �• O W Iwhlfythat]have read this appllationand natethattheabove loformation �� Ill. is cored.I.S.to comply with all dtyand rountyordinanres..dstatelaws PERMIT ISSUANCE F S } N relatingtolullding construction,and hereby authorte repreaentaBveao(this 1— U) city to enter upon the above-mentioned property for Inspection purposes, ALTERORADDTOMFLH. — _ (We)agree to save,indemnity an d keep harmiess the City f Cupertino to Recei f# against Babill0egjadgmerds,cosband expenx.w mayl ywayacaue AIR HANDLING UNIT I0,0DOCF'M) S TOTAL' against a CityIn consryue (the granting bps AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION AkX S reo Bant/Cont Date EXHAUST HOOD(W/DUCT) CONSTRUCTION T X PAID: HAZARDOUS MATER IAL ISCLOSURE Will PpBantm(uture building ant storeor handle hazardous HEATING UNIT(TO 100,000 BTU) Date R 1 # material defined by the Cupertino Municipal Code,Chapter 9.12,and the _ Heshhand S.fay Cade Section 25S32(a)? HEATING UNIT(OVER 100,000 BTU) TO A F-11Yee M No Y Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE TE which emit hazardous air contaminant.as defined by the Bay Area Air Qu lity Management Din❑strict? BOILER-COMP DHP OR 100,000 BTU)N. ppyy pp *a�read the bazardousinsterials requlreneenta under Chapter 6.95 of BORER-COMP 100,000 BTU) P M Y D the Califernb Health&Safety Code,Seaton.25505,25533 and 25539.I understand that if the building does net cvrtently have.tenant.that it b my NEW RESIDENTIAL MECH. SQ.FT. _ raporulbility to notify the..pant of the requirements which must be met e prior to issuance of a Certificate of Occupancy. 'JULUU vt� r aaL v 11VV Owner or authodud agent Date ISSUED BY: 1 OFFICE COPY