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23965 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY Building Project Identification PERMIT NO. Building Address: 23965_n C C AS 9 I6 J A& (I�itf G e ante: q one: p 73.3 / CITY OF CUPERTINO-BUILDING DIVISION �� Archlte°^ s�� Lie APPLICATION / PERMIT •' 1 BMDINGMECHA ELECnUCALMUMBING- MCAL CATEGORY CONTROLN t/Engineer. Lk.No: QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO Add. PERMITISSUANCE ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION Ihereby alfirmthet l am licensed under provisions o(Chapter9(mmmmc APPLLANCESRESIDENTIAL F N Ingwlth Sedion7000)o(DIWNon3oftheOuslnemand ProtesslonsCode and eny license is In fill form defect. PONTIS Lto nse Class Ile N �9 Date'Z ' i/' , CnnITEC w SSW, 7nd7ta1�apARCHITECTSDECLARATION OVER AM reO Zp luMeretand my plans shall be used as pubkcremnds. OVER 1000 AMPS SQ.FT.FLOOR AREA 3/SQ.Ff. }a od�j Licensed Profenlonal SIGNS ELECTRICAL OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC Z1�°--, thereby affirm that l am exempt from NLicense e Contractor's law fee the p owing reason.(Section 70315,Business and Professions Code:An tl or F 1"ty following which require,a permit to construct,alter,Improve,demolish,or repair TEMP.METIER OR POLE]NST. 7 any structure prior to its lasuaneq alto requires the applicard for such permit to POWER DEVICES 5 Bk a signed statement that he Is Learned pursuant to the provisions of the 3w Contractors License Law(Chapter 9(commencing with Section 700)of Divi- SWIMMING POOL ELECTRIC VALUATION O slon 3 ofthe Business and Professions Code)orthat he is exempitherefromand 6 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFIXTURE5 applicant fora permit subjectsthe applicant to a civil penalty of not more than five hundreddollars he pr. NEW IIMDFNTIALELECTR SQFr. STORIES TYPE CONSTRUCTION �n ❑easowrsro(lheproperty,orhesemploy. ure,Is withwagn atheresok C wmperuatlon,wilidothe Business and Professions Code:rcbn Contractontendedrs stuffs Law 5 O sald for e(Sec.apply to an ow and f property Code:The C impro es LAcethereon law S$ does not apply to an owner d property who builds or improves thereon,and OCC.GROUP RES.UMTS whodoessuchwork timenclethrough Meown<mplogeeseProvhe building that or Impmvementaarenot Intendedoro((ec fee aak.ILhowev builderwilve TOTAL: Improvement badd within one yeamfcompldlon,the ownerbullderwlll have to Nen of proving that he did not Wild or improve for purpose ofsak.). QTY. PLUMBING PERMIT FEE FLOOD ZONE "N Lj L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE / - contractors to construed the project(Sec 7044,Businessand Professions Cade: all as� The Contractor's Licann Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(Ep) Wilds or Improve thereon,and who contracts fee such pkoketa with a contractor(s)licensed pursuant to the Ce nteactors License Law. FEE SUMMARY LJ I am exempt under Sec B&P C for this reason BACK FLOW PROTECT.DEVICE DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N . Owner Date RECEIPT_ NN WORKMAN COMPENSATION DECLARATION ? pIXNRES PER TRAP SCIi00L TAX Y N ❑I heeoby affirm that I have•certificate of consent to copy therne ora .7 �'�•s RECEIPT N certi(Icata o(Workene'C m nsatlonlnsurance oraeartified ropy thereof(Sec. CAS EA.SY3rEM-1 ING4OUTLE S PARK PER Y N 3N0,Iab C.) _q o&j ^ { R 1 Camryan �L�dJ �I/ CAS FA.SYSTEM.OVER 4 LEM DING DIN y BUILDING DIVISION FEEL Certified copy b filed with the city 4 mity Impaction division. wci GREASE/ oUSIRL WASTE INTERCEPTOR PLANCHECKFEE Cc CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 20F1• Date Recei [# (Thissection need rad be eemplded](the permit Moronshundrod dollars (f10)ml that WATER HEATER W/VENT/ELECTR ENERGY FEE Y N I certey CthaU the performance of weak for this permit Is boned, I shall not employ any person In any manner"to become subject to the WA SYBIEM/TREAI7NG r� Worker Compensation IAwso(Callfomia,Date/ PAID OZ Applicant NEW RESIDENTIAL PLMB. SQ.Fr. Date Recei t# Z O NOTICE TO APPLICANT:If,ager nuking this Certificate of Exemption,you should became subject to the Worker'Compemation provisions of the Labor TOTAL: S2 Code,you coast forthwith comply with such provlsbns or this permit shall be B LU > domed revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE CL Ihercbya(firm that there is a cemtmctlon lendingagencir for the perform. ELECTRIC FEE M Z ancooftheworkforwhieh this permit is Issued(Sec.3097,CIv.C.),' T ^' V O Lender.Name PLUMBING FEE LL F- Landar.Addren - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE 0 W Imrilythat l have mad this applicotion and statethatthe abovelnlom tion CL bcorred.I agree locomply with all city and county ordinances and pate lawn PERMIT ISSUANCE FEES PAID: miatingto Wlldingmmtrudion,andherebyauthorlaempremntativ o(thls F Z city to enter upon the above-mentioned property for Inspection purposes. ALTFRORADDTOMECH. Date Recei t# _ Me)agme to save,indemnity an d keep harmless the City of Cupertino against liabilities,judgem ts,cost..ed expenses which may In any wayacerue AIR HANDLING UNIT(TO 10,ODO CFM) SUBTOTAL: against said City In cunmVenm of the grant Ing of this permit. AIR HANDLING UNIT(OVER 10,00 CFM) CONSTRUCTION TAX Slgnsture of AppLicant/Contractor - Data E)CHAUSTHOOD(W/DUC) CONSTRUCTION TAX PAID: HA2A R DOUS MATERIALS DISCLOSURE _ Will the a ppllcant orfuture building occupant store or hand Is haaallous HEATING UNIT(TO 100,00 BTU) Date Recei t# material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 10,000 BTU) TOTAL: RYes N No Ol the applImat or lune resbuilding oecepani use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE which rent hariNous air coots mimnts as defined by the Bay Area Air Quality Management District? BOILER-COMP OHP OR 10,00 BTU) PYes No &q h ave read the haaa ouseneterlals requlrcments under Chapter 6.95 of MOILER-COMP(OVER 100,000 BTU) y" A D the Galifernla Health&Safety Code,Sections 25505,25533 and 25534.1 understand that lithe building does not currently have a tenant that it is my NEWRESIDENTIALMECI. SQ17 responsibilitytoofathea Certificate of the requlrcmentswhich rtwst be met prior to Issuance no a notify the oc to of Ottvpareq or d g ?Date ISSUED BY: IIIYV TOTAL: OFFICE COPY APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY Building Project Identification PERMIT NO. Building Address: 23965_n C C AS 9 I6 J A& (I�itf G e ante: q one: p 73.3 / CITY OF CUPERTINO-BUILDING DIVISION �� Archlte°^ s�� Lie APPLICATION / PERMIT •' 1 BMDINGMECHA ELECnUCALMUMBING- MCAL CATEGORY CONTROLN t/Engineer. Lk.No: QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO Add. PERMITISSUANCE ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION Ihereby alfirmthet l am licensed under provisions o(Chapter9(mmmmc APPLLANCESRESIDENTIAL F N Ingwlth Sedion7000)o(DIWNon3oftheOuslnemand ProtesslonsCode and eny license is In fill form defect. PONTIS Lto nse Class Ile N �9 Date'Z ' i/' , CnnITEC w SSW, 7nd7ta1�apARCHITECTSDECLARATION OVER AM reO Zp luMeretand my plans shall be used as pubkcremnds. OVER 1000 AMPS SQ.FT.FLOOR AREA 3/SQ.Ff. }a od�j Licensed Profenlonal SIGNS ELECTRICAL OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC Z1�°--, thereby affirm that l am exempt from NLicense e Contractor's law fee the p owing reason.(Section 70315,Business and Professions Code:An tl or F 1"ty following which require,a permit to construct,alter,Improve,demolish,or repair TEMP.METIER OR POLE]NST. 7 any structure prior to its lasuaneq alto requires the applicard for such permit to POWER DEVICES 5 Bk a signed statement that he Is Learned pursuant to the provisions of the 3w Contractors License Law(Chapter 9(commencing with Section 700)of Divi- SWIMMING POOL ELECTRIC VALUATION O slon 3 ofthe Business and Professions Code)orthat he is exempitherefromand 6 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFIXTURE5 applicant fora permit subjectsthe applicant to a civil penalty of not more than five hundreddollars he pr. NEW IIMDFNTIALELECTR SQFr. STORIES TYPE CONSTRUCTION �n ❑easowrsro(lheproperty,orhesemploy. ure,Is withwagn atheresok C wmperuatlon,wilidothe Business and Professions Code:rcbn Contractontendedrs stuffs Law 5 O sald for e(Sec.apply to an ow and f property Code:The C impro es LAcethereon law S$ does not apply to an owner d property who builds or improves thereon,and OCC.GROUP RES.UMTS whodoessuchwork timenclethrough Meown<mplogeeseProvhe building that or Impmvementaarenot Intendedoro((ec fee aak.ILhowev builderwilve TOTAL: Improvement badd within one yeamfcompldlon,the ownerbullderwlll have to Nen of proving that he did not Wild or improve for purpose ofsak.). QTY. PLUMBING PERMIT FEE FLOOD ZONE "N Lj L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE / - contractors to construed the project(Sec 7044,Businessand Professions Cade: all as� The Contractor's Licann Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(Ep) Wilds or Improve thereon,and who contracts fee such pkoketa with a contractor(s)licensed pursuant to the Ce nteactors License Law. FEE SUMMARY LJ I am exempt under Sec B&P C for this reason BACK FLOW PROTECT.DEVICE DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N . Owner Date RECEIPT_ NN WORKMAN COMPENSATION DECLARATION ? pIXNRES PER TRAP SCIi00L TAX Y N ❑I heeoby affirm that I have•certificate of consent to copy therne ora .7 �'�•s RECEIPT N certi(Icata o(Workene'C m nsatlonlnsurance oraeartified ropy thereof(Sec. CAS EA.SY3rEM-1 ING4OUTLE S PARK PER Y N 3N0,Iab C.) _q o&j ^ { R 1 Camryan �L�dJ �I/ CAS FA.SYSTEM.OVER 4 LEM DING DIN y BUILDING DIVISION FEEL Certified copy b filed with the city 4 mity Impaction division. wci GREASE/ oUSIRL WASTE INTERCEPTOR PLANCHECKFEE Cc CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 20F1• Date Recei [# (Thissection need rad be eemplded](the permit Moronshundrod dollars (f10)ml that WATER HEATER W/VENT/ELECTR ENERGY FEE Y N I certey CthaU the performance of weak for this permit Is boned, I shall not employ any person In any manner"to become subject to the WA SYBIEM/TREAI7NG r� Worker Compensation IAwso(Callfomia,Date/ PAID OZ Applicant NEW RESIDENTIAL PLMB. SQ.Fr. Date Recei t# Z O NOTICE TO APPLICANT:If,ager nuking this Certificate of Exemption,you should became subject to the Worker'Compemation provisions of the Labor TOTAL: S2 Code,you coast forthwith comply with such provlsbns or this permit shall be B LU > domed revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE CL Ihercbya(firm that there is a cemtmctlon lendingagencir for the perform. ELECTRIC FEE M Z ancooftheworkforwhieh this permit is Issued(Sec.3097,CIv.C.),' T ^' V O Lender.Name PLUMBING FEE LL F- Landar.Addren - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE 0 W Imrilythat l have mad this applicotion and statethatthe abovelnlom tion CL bcorred.I agree locomply with all city and county ordinances and pate lawn PERMIT ISSUANCE FEES PAID: miatingto Wlldingmmtrudion,andherebyauthorlaempremntativ o(thls F Z city to enter upon the above-mentioned property for Inspection purposes. ALTFRORADDTOMECH. Date Recei t# _ Me)agme to save,indemnity an d keep harmless the City of Cupertino against liabilities,judgem ts,cost..ed expenses which may In any wayacerue AIR HANDLING UNIT(TO 10,ODO CFM) SUBTOTAL: against said City In cunmVenm of the grant Ing of this permit. AIR HANDLING UNIT(OVER 10,00 CFM) CONSTRUCTION TAX Slgnsture of AppLicant/Contractor - Data E)CHAUSTHOOD(W/DUC) CONSTRUCTION TAX PAID: HA2A R DOUS MATERIALS DISCLOSURE _ Will the a ppllcant orfuture building occupant store or hand Is haaallous HEATING UNIT(TO 100,00 BTU) Date Recei t# material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 10,000 BTU) TOTAL: RYes N No Ol the applImat or lune resbuilding oecepani use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE which rent hariNous air coots mimnts as defined by the Bay Area Air Quality Management District? BOILER-COMP OHP OR 10,00 BTU) PYes No &q h ave read the haaa ouseneterlals requlrcments under Chapter 6.95 of MOILER-COMP(OVER 100,000 BTU) y" A D the Galifernla Health&Safety Code,Sections 25505,25533 and 25534.1 understand that lithe building does not currently have a tenant that it is my NEWRESIDENTIALMECI. SQ17 responsibilitytoofathea Certificate of the requlrcmentswhich rtwst be met prior to Issuance no a notify the oc to of Ottvpareq or d g ?Date ISSUED BY: IIIYV TOTAL: OFFICE COPY