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23761APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Pru'ed Identification Building Address: /� t %`Zy� Piino'Ca ci CIypW7t(ro PERMIT NO. % 237 61 wners/�/ one: I R1ar Me! 1lexl/e_ 257-3626 CITY OP CUPERTINO-BUILDING DIVISION APPLICATION I PERMIT BUfLDINGELECTRICAI PLUMBINGMECIlANICAL p 6 con ""' Lit. N.: CATTLORV CONTROL X Architect/Engineer: -Lie. No: QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO Address: ❑ ❑ PERMITISSUANCE �'� LICENSED CONTRACTOR'S DECIA RATION I hereby&filrm that l son Ilmosad under provisions of Chapter 9(commne ingwith Sect10n7000)o(Dlvislon3oftheBusimmand Pmfeaslon$Codgand my, time. IS In full form and effect. Limn. CkssLk.X Date Contractor APPLIANCES -RESIDENTIAL JOB DESCRI'IIONrX� s7 W1 IJ ��� 1 • , t , L eV W (�Q 'T PANFIS AMPS ARCNITECTSDECLARATION I understand my plans s1uI1 be used es public records Licensed Professional OVEOO 000AM OVER 1000 AMPS SQ. FT. FLOOR AREA %� © IN A f/SQ. FT. SIGNSELEC'IRICAL t SPECIALCItCUIT/MLSC '- OWNER -BUILDER DECLARATION I hereby affirmthat l am exempt from the Contractor's License law forthe �' s� C-� lye lj 1.a 1 i TEMP. METER OR POLE INST. following reason.(Section 703IS, Business and Pro(essiuns Code: Any city or county pmvSdennlbh,orrepalr rtyubeea pertNttomrmuct,orequi alter,esth L,d B ^ / cturewhich a aborequlmsuant t the providersorsuch tto any dmcture pater feIts hat he o file a signed statement that he b licensed pursuant to the provblona of theOAT Conlndors License Law (Chapter 9 (commencing with Section 7000) of Divi- sion3 o(the Busineaeand Pmf..bm Code)orthat he b exempttherefromand the bash for the alleged exemption. Any violation of Section 7R31S by any applicant ora permit subjects the applicant to a civil pemltyotnot morethan POWER DEVICES SWIMMING POOL ELECTRIC - OUTLETSSWITCHESFIXT URFSt I VALUATION i 1 �/ t� {L (5t f ndreddollar(f500). I, as owner of the properly, or my employees with wages as theb sok NEWRIESIDENTIALELECTR uQ.FT. STORIES TYI'ECONSIRUCTION o n.tion, wlltdothe work and the structure is not Intended or offered for vie (Sec 70M Business and Pro can.. Code: The Contrdols Lt.. Taw does not apply to an owner of property who Wilds or Improves thereaR and who doessuch work himself orthrough hlsown employees, provided that such OCC. GROIIIx RES. OMITS improvements are not Intended orieffered forsale, It however, thebuilding or improvementissold withlnomyearofcomple Wb theowner-bullderwlll have TO tl)f,kurden of proving that he did not build or Improve for purpose ofiale.). LJ L as owner of the property, am exclusively contracting with Ilcensed contractors toconstruct the project (Sm. appyBusiness and Code: QTY. PLUMBING PERMIT FEE PERMIT ISSUANCE FLOOD ZONE APN The Coor lonpr'a License Law aces net apply to s f owner d property who w of builds t r Improvee tpursua and who contracts tier such ptokde with e cgBlEactm exempt under Se.tothe Contrdofs Llanse Law. 1-J I am exempt under Sec. B & P C for this reawn ALTER -DRAIN & VENT- WATTS (EA) FEE SUMMARY BACK FLOW PROTECT. DEVICE DRAINS FLOOR ROOF, AREA, CONE. p0(TUgES PER TRAP SANITARY Y N_ RECEIPT Owner Data WORKMAN COMPENSATION DECLARATION C31 hereby affirm that I have a mrtl0erm of consent to selFinmre, ora adilateof Workmi Comperodonln mnmoraaAlfkdmpytheerof(Sec. Lab C.) SCITOOL TA% Y N N RECEIPT3800, CAS FA. SYSTEM -1 INCA OUTLETS PARK FEE Y N Policy N RECEIPT M CAS FA. SYSTGM-OVER4 (EA) Cany omOCedmed BUILDING DIVISION FEES copy Is herebytty OCcrtlled copy b (fled withh (he the city Inspection division.GREASE/INDUSML WASTE INTERCEPTOR PLANCHECK FEE S 2 CREASETRAP CERTIFICATE OF IXEMPTION FROM WORKERS' COMPENSATION INSURANCE R) m.dlon need not b completed lithe permit b (ararm hundred dollars 0100)af1yth permit cttothIssued, tm caner an as t becomh this e I ll not that In any personhe In 1 .,k not employ any person N any manner n u to beams mbjed to the Workere'CompensaHon laws o(Glifomk. Date PAID Date Reoei t# SEWER -SANITARY -STORM EA ]OOFI. WATER HEATER W/VENT/ELECTR ENERGY FEE Y N PAID WATER SYSTEM/TREATING NOTICApplicaE NOTICE TO APPLICANT: If, aper making this Certificate of Exemption, you should become subject m the Worker' Compensation provisions o(the Labor Code, you at forthwith comply with such provisions orthb permit shall be domed revoked. Dale Revel f# NEW RESIDENTIAL PLMB.__SQbT. -.BUILDING TOTAL: Isaw SEISMIC FEE CONSTRUCTION LENDING AGENCY Iherebyaflrm that there It a construction lendingagency forthe perform,- arm .(the work forwhich this permit b Lsmed (Sec. 3097, Clv. C.) Lender'. Name Lenders Address I cedilythat I have mad thisapplicuakmand date thatthe above In(ormatlon Is correct. l agree to comply with all city and county ordinances and state laws TOTAL: ELECTRIC FEE QTY. MECHANICAL PERMIT FEE ' PLUMBING FEE MECHANICAL FEE PERMITIS91JANCE FEES PAID. relating to building construction, and hereby authorise representatives o(tAb cry toenter upon the ahxwcmenHondprepedy for Inspection purposes. (We) agree to cave, Indemnify an d keep harmiess the City of Cupertino agaust liabilities, PcIgnmets, mstsand expenses which may In any wayaorue agitl.. id City In consequence of the Erring of this permit. n X' /(k 4)O Vy �7/V A'Daate7< ALTER OR ADD TOMECH. Date Receipt# AIR HANDLING UNIT (TO 10,000 CFM) SUBTOTAL: AIR HANDLING UNIT (OVER 10,000 C[ M) CONSTRUCTION TAX Signa�turere.1'A(pplleaam/Cmarrset r�y:uA DaiAus r Ilow(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant.' future building omp.m.torear handle hacardous material as defined by the Cupertlno Municipal Code, Chapter 9.17, and the Health and Safety Cod Section 2x537(a)7 F1 yon No Date ReceI t# HEATING UNIT 100,0DO BT I) _ HEATING UNIT(OVER 100,000 BTI) TOTA {„/ C VENTILATION FAN (SINGLE RESIDE ISSUANCE DATE Illtheapplicant or tum building occupant useequipment ordevices which tout hazardous air comuntrunts as defined by the gay Area Air BOILER-COMP011POR100,000gTU) a lity ManagementIstrict7 Yea No AOILBR-COMP(OVER 100,000 BTU) have mad the M1azr us materials requirements under Chapter 6,95 of lie California Health&Safety Code, Sodium 75505,75533 and 75534. I understand that If the building don not comedy have a tenant, that it is my retparoiblllly to notify the occupant of the requirements which must be mot �prior issuance of a Cerll/ale of0capancy. �Q � VILLI( 6lz gz It PAID W 9 Xpti/ JUN -$. 19/J{.ry�/ NEW RESIDENTIAL MECH. SQ.FT. Oweermauthorizedagent Data 1SSUfi� : t 'V11 TOTAL: OFFICE COPY