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23105 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Perin Identification 7 PERMIT NO. Building Address:009 23105 Uwn cera Name 111hone: A '« CITY OF CUPERTINO-BUILDING DIVISION contr•no: ame: / ueNn: APPLICATION /PERMIT Sc"ra la) AI a a�gZ5 BUILDING-ELECUUCAIPLUMBING-MECHANICAL CATEGORY CONTROL Architect/Enginer Lk.No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: FERMITISSUANCE ❑ Ela LICENSED CONTRACTOR'S DECLARATION Ihereby licensed under onsof C9(mmmrnc APPLIANCES JOB DESC ON Ingwlih Seedon7000)oHNssicit3oftheBusiessuandProfeseximuCode,and my license is In full(pgce.V effect. per]/ PANELS License CbuC' C�MLic.N 0 / /J / W {e Datf_ Com^ •TContraaor U phkmBfit CUP TO 2DO p110WAIAM O ARCHITEPSDECLARATION OVER1000AMPS SQ.Fr.FLOOR AREA S/SQ.FT. p�p�uu PS oy� I understand ion plan shall be used u public records. LED I N E U Licensed Professional SIGNS ELECTRICAL <Q m OWNER-BUILDER DECLARATION p jq1 R SPECIAL CIRCUIT/MISC 71„ Thereby affirm thetlam exempt from the Cont ractore Llcenx Law for the 1 F pO following ichreq(Soddene] tto umt ea t r imp ons emle hnytlty or A/ �OZ TEMP.METER OR POLE WST. {/)ceuntywhlchrcqulresapermittomnstruQiltenImprovederrolbhorrcpalr Q raystructurepriortoitsIssuance,alsurequirestheapplicantforsuch permit to POWER DEVICES 3 6�y file a signed statement that he is licensed pursuant to the provisions of the Contractor'.License Law(Chapter 9(mmmentlng with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION O sloes 3 of the Budedia.nd Profeulons Code)or that he is exem therefmand y.' the basis Ior the alleged exemption. Any violation of Se tion m7ML5 by any OU7LETSSWIT'CHESFIXTURES applicant for a permit sub)ecs the applicant to a civil penalty of not more than five hundred dollars($SM. ni,as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELECTR SQ.FI'. STORIES TYPE CONSTRUCTION Z¢ compensatlon,wllldothewarkandthestm umhnot intended or offered for �❑ sale(Sec.7044,Business and Prolessbns Code:The Contractors License Law $� does not apply to an owner of property who builds or improves thereon,and OCC.GROUI' RES.UNITS whodoessuchworkhim ff.rthmugh Msmwnemployees,providedthatsuch Improvements are not intended mattered forsale.If,however,thebullding or TOTAL: improvement issold withinoneyearofcomplelion,theowner-builderwill have tl)rJiurden of proving that he did not build orimpewe for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN Ll L as owner of the property,am exclusively contracting with licensed ppRM17155UANCE �a contractors to construct the project(Sec 7044,Business and Professions Code: Tire Contractor's License Law does not apply to an owner of property who Wilds or Improves thereon, and who cocts n for such p(ojes with a ALTER DRAIN&VE#T-WATER(EA) ontra onnt[actoKs)licensed pursuant to the Cantrators License Law. FEE SUMMARY LII am exempt under Sec. B&P C for this mason BACK FLOW PROTECT.DEVICE OUTSIDE FEES DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y— N • Owner Dale REC©PIp WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCIIOOL TAX Y_ N_ r_11 hereby affirm that 1 have a certificate of consent to self-insure,ora RECEIPT'N certificate of Workers Compensation[nsuraneema certified copy thersof(Sec. GAS E.A.5YSTEM-1 INCA OUTLETS PARK FEE Y N 38W Lab C) n l I'oliq N G /OOp`p2— I GAS FA.SYSTQAAVFR 4(EA) RECEIPT N Co�any AM ( BUILDING DIVISION FEES Certified copy Is herebyththe e . GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE Certified copy Ls filed with the city Inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200Ff Date Recei t# Qhi.setion need not W completed If the permit ii foram hundred dollars (SIM or Ica•.) WATER FIFATER W/VENT/ELECTR ENERGY FEE Y_'N_ I certify that in the peAormance of the work forwhich this permit is Wood, I shall not employ any person In any manner so u to become subject to the WATER SYSTEM/TREATING Workers'Compensatlon laws of California. Date PAID OZ Applicant NEW RESIDENTIAL PL.MB. SQFr. Date ReCtil t# Z O NOUCETO APPLICANT.10iter ma king this Certiflcateaf Exemption,you should hemme sublet provision of the Workers'Compeuation provisioof the Labor TOTAL: III Code,you most forthwith comply with such provisions or this permit shall be BUILDING FEE W 9 deemed revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE O. I hereby affirm that there V a construction lending agency for the perform O ELEC'T'RIC FEE M Z ante of the work for which this permit is Issued(Sec.3097,Civ.C.) PLUMBING PL•E () O lender'.Name H Lender.Addie.. QTY. MECHANICAL PERMIT I'EE LL U Icertifythat I have mad this applicatlonand state that theabove information MECHANICAL FEB O W Lsoorrect.Iagomtocomplywithallttyand countyorduancessndstatelaws PERMIT ISSUANCE FEES PAID: } fl relating to Wilding construction,and hereby authorize mprceentatives of this 1— Z city to enter upon the above-mentimuN property for lapetion purpose•. ALTER OR ADD TO MECH. (We agree to save,Inde fy an d keep barreled;the City of Cupertino Date Receipt# against Iabilteiim;ud fits, stsandexpenses hi It ylnanywayaccrue AIR HANDLING UNIT(TO 10,QX0 CFM) SUBTOTAL: U — gai dCity In o e W ting of I. it. R/�/a� s /_�1' AIR HANDLING UNIT(OVER 10,000CrM) CONSTRUCTION TAX Sig�Pp icmt/Co tra or E Date 9�L EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will theappffeant or him.buildingoomp.M.toreor handle hvamdous HEATING UNIT(TO 100,000 BTI) Date Reuel t# material as defined by the Cupertino Municipal Code,Chapter 9.12,and the — Illcalth and Safety Cade Section 75532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: ❑ Yes In No Will the applicant or future Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE which cont havrdous air contaonstnts as defined by the Bay Area Air R9 Quality Management District? BOILER-COMP OHP OR 100,0(10 BTU) Ir Yes ❑No Thsee read the hazardous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100.000 BTU) 9 ��npl 211992 the Glllomh Health&Sa/ety Code,Sections 25505,2553]antl 15534. 1 1tl Ia understand that if the building does not currently have a tenant,that It is my NEWRESIDENTIALMECH. SQTT r1 responsibility to notify the occupant of the requirements which most be met ptortolssuanmofaCetiflcateofOmrpancy. City uf(```�U/p�CI�11�11VV Owner or authorized agent Date IISSSUEDHy..r ' � - Zia. TOTAL: ✓'s�— OFFICE COPY