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23146APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY . Building Project Identification- Building Addreu:' ' 0W v�R. �`Rct.E PERMIT NO. '. 23146 an,e � wriereone: CITY OF CUPERTINO-BUILDING DIVISION APPLICATION / PERMIT BITILDING-ELECTRICALPLUMBINGMECHANICAL �.1� cMIIIK o trader���/5�7 Lk. No: "" �V J-/ '{,.Q Al� 63 CATEGORY CONTR BUILDING PERMIT INFO A, d/Engineer.le. No: oo�)il ties 7'�4�• 6_12" QTY ELECTRIC PERMIT FEE / Address:' 0, S/lSoqAl 7efttvqNDfl Jr PFRMITISSUANCE LICENSED CONTRACTOR'S DECLARATION + - Ihereby affirm that lam licensed under provisions Of Chapter9(c..1- 1xv.se.tingwith fon7000)of d dieon3eflheBual 6andlsrofeegona Code, and my license la in full f and effect LkenseC ss Conp %r/ C .l Date Z L L Contractor VCaN APPLIANCES -RESIDENTIAL JOB DESCRI'ITDN ^ ���Q� - 1!'Y' - PANELS I I (UP TO 200 AMPLql 201-10D0 AMPS ' ARCHITECPS DECLARATION I understand my plana shall be used as public records. " OVERIOWAMPS SQ. FT. FLOOR AREA - $/SQ. FT. SIGNSELECTRICAL Licensed Professional SI'ECIALCIRCUIT/Mise OWNER -BUILDER DECLARATION ff l am frolaw for the I hemwing TEMP.METEROR POLE INST. . (Seat m 31.5, Business a d Peafdor'slicense or fogowtngreh requi gaperction 031.5,mand Proprove, Code: Any mpair nuntyrequlreta permitto alter,esti improve, demsor aity uch,er mit to Structure also, reuct,quires fileany atmduretaprior menIts hIssuance, Is lice regpursuant to the revisionsch of to Co a signed statement that he ler 9 (care pursuant it the provisions of the Lew erdea oesCom) ucingorthat with xection mptthe00)of Divi- Contracture Business Code) iothat hob exempt therefrom and then3 of the Bu a aIle and P exemption. by any the Baan for the alleged exemption. Any violation of Section net room . app hundredt for dolism $500). Subjects the applicant tea civil penalty of net more than five 1, as own r of the pr . MI, as owner of the property, or Ory employees with wages thele POWER DEVICES - VALUATION ' SWIMMING BOOL ELECTRIC '; OUTLETSSWITCHES-FTXITTRES W RESIDENTIAL ELECTR SQ.FI SIORLES TYPE CONSTRUCTION tion, work and the r or offered for cols - - (See (Sec. W.Jeou and ssions ode: Th Contraet ctor's Code: The C License License Gw an Law doe apply to ow f property, Improves whodes otapply torn ownerofprough his wnemeoyees, provided that hisownemp,Oyees,provtded whodvessuchments OCC.GROUP RES. UNITE aorkMmaendedorwgh he ildingch Improvements intendeeyearofoomplr offered far lkenthe owevey ilderwillhaw as, Improvement laeold wlthinoneyxaro(completbrytbeownervbu0derwill have TOM Cr ' tllf,�Iiurdeo of pawing that he did net build or improve for purpose ofule.). u L as owner of the property, am exclusively contracting with licensed contractors to constmd the project (Sec. 7044, Business and Professions Code: QTY, PLUMBING PERMIT 'FEE FLOOD ZONE APN ' PERMIT ISSUANCE The Contractors License Law don not apply to an owner of property who Wilda or improves thereon, end who contracts for such p(Ojede with a d caor(e) licensed punan gB(futroths Contradorb Llmnx Law. nal am exempt under Sec. B k P C for this renonOUTSIDE - ALTER -DRAIN k VENT - WATER (EA) FEE SUMMARY ' BACK FLAW PROTECT. DEVICE + FEES DRAINS FLOOR, ROOF, AREA, COND. SANITARY Y N RECF9T X Owner Data WORKMAN I haw. COMPENSATION DECLARATION ❑I hereby affirm that I hive o legum of consent to elf-insum, ora 3800, Late of Workers Comps tionlmurantt oracertified cepy[hereof (Sec. Policy It ' cP 0/3399 T C,Pa FIXTl1RE4 PER TRAP l•' - SCHOOL TAX Y_ N_ RECEIPT p GAS EA. SYSTEM -I INC4 OUTLETS PARK FEE Y N ' REC®II'X GAS EA. SYSTEM-OVERd(EA) C. -ate I T tI ON ' BUILDING DIVISION FEES ertlfted copy is hereby te �Certl(led copy g filed withh the cityInspection division. ty CERTIFICATE OF EXEMPTIONGREASE FROM WORKERS' GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FaEE,, d'TT/ PAID TRAP SEWER -SANITARY STORM F.A. 200FT. COMPENSATION INSURANCE f (Thtssectlenneed not becompleted ifthepermit isforone hundred dollars . Re WATER ]-[EATER W/VENT'/ELECTR ENERGY FEE Y N q PAID ` 1 ($100)orless.) I certBy that In the performance of the work for which this permit is "Sued, I shall not employ any person in any manner ao as to become subject to the Workers Compensation laws of Callfomla. Data WATER SYSTEM/TREATING Applicant NOTICE TO APPLICANT: If, after making This Certificate of Exemption, you Should became Subject to the Workers'Compensatlon provisions of the Labor Date Revel t# NEW RESIDENTIAL PLUM. SQ IT • OTAL:' Code, you must forthwith comply with such provisions orlhis permit shall be domed revoked. BU DI SEISMIC FEE;24 wawrw CONSTRUCTION LENDING AGENCY Ihereby affirmthat there Is a construction lending agency forthe perform. ance otthe work for which this permit is issued (Sec.3097, CIv. C.) Leader's NaivePLUMBING Landers Address - I certifythatl have read thisapplicettenand statethatthe above Information Vcorrect. I agree to comply with all city and county ordinances and gate laws TO ELECTRIC FEE L FEE 'Sd QTY. MECHANICAL PERMIT 'FEE PERMIT ISSUANCE MECHANICAL FEE FEES PAID: relating to building evetrudion, and hereby authorte, representatives ofthis city to enter upon the above-mentioned property for Inspection purposes. (We) agree to save, indemnify an d keep harmless the City of Cupertino against llabllltlery rydgmenta, grand expenses which may ln.ny wayaceme Date Receipt# ALTER OR ADD TO MECH. AIR HANDLING [)NIT QO ]0,000 CFM) SUBTOTAL: agairart Sal rin consap(j sof the gr Ing offife penNt Jf q / AIR HANDLING UNIT (OVER 10,000CFM) CONSTRUCTION TAX Sig " Ctore of App ontrao Date D(]iAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAA HAZARDOUS MATERIALS DISCLOSURE - • HEATING UNIT (TO IDgODO BTU), '. 111 the applicant or future building occupant afore or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safe-yesty Cod e, Section 25532(a)7 "Date Recei t# t HEATING UNIT (OVER 108000 B= �f TOTAL: VENTILATION FAN (SINGLE REBID) -• ISSUANCE DATE " Wllltheappllcant orfuuturebuildingoccupant use equipment ordevion which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District? - 4 Yea N us e requirements of , have read the hazy oet Brad - P A I D , BOILER -COMP OHP OR 100,000BTU) BOILER -COMP (OVER 100,000 BTU) Code,materiSections2553 255 4.-1 the creta rola Health & building Code, Sed urre ntly have a meant, nd 25534: I ' understand that notif the the ocgdon not erequire encs whichthat It is at requirements which must be rtet responsibilityriortc of aCabe occupant of Cheops my. prior to Issuance ofa Certltkate o(Oavpanry. 11 1 FEBk 2 T 2 7 ��� NEW RESIDENTIAL MECH. SQ.FT. ISCITY SLIEDBY: Owner or authorized agent Date TOT , OFFICE COPY