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22678 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification - P]RMBTNO. Oudding'Addrust: voL.C1 K4,8uS c 22678 s n' APPLICA7T0V7I79RITrAT= ter pt,lA-6 E7 �p,Szj CITY OF CUPERTINO�BUILDING DIVISION CanaIr LI=Na APPLICATION I PERMIT BUILDING-ELECTRICALPLUMBINGM/FLHAMCAL CATEGORY CONTROL Architect/Engineer. Lie No: QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO Address: PERMITISSUA.NCE lal� ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION L71 Ihth Seaon7Othat I am)ofDivsi=3ofed underpenandmfenionsCocommon APPLiANCESRESIDFMTAL JOB DESCRIPTION inenseISection force it died. PANELS my J - -�S ' license la In s (arm and c.# PANELS LicenseClaes LION Date Ccorrector UP TO 200 ANTS L ARCHITECPS DECLARATION 201-1000 AMPS q�q�uu p O I understand my pons shall W used u public records. OVER 1000 r I I R AREA $/SQ.FT. k 2kd Licensed Profimal SIGNS essELECTRICAL _ r OWNER-BUILDER DECLARATION I 1 - I'n SPFCIALCRCUI7/ L o ('. f l I I lv p, ]hereby a(flrm that lam exempt from lhe Cantractor'•Llcenu Law for the M _ �.. following reason.(Section 7031.5,Business and Professions Cade:Any city or T P.MEHR OR POL NST. N�,a county which requires permit lnmnstroM slurs Improve,demolish,or repair qany structure prior to its issuance,also mquirssthe applicant foriuchpermit to POWER DEVICES DATE E°0 F ilk a signed statement the he It licensed pursuant to the provisions of the 3w Conlrs cemeawl pler anor' Lll (C9h&tt1on70ofDwi- 110) OI-n (commentl ,g lSWIPIMING POOL ECCRIC eon3 of the Bu ualneand Pro(enbns Code)orthat hell erempttherefromand VALUATION the bash for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFIXTURES O` SEGW75J applicant fora permit subjects Nm e applicant to a civil penalty of nmore H /nun ` ) five rifted dollars($500). SQ.FT. STORIES TYPE CONSTRUCTION as owner of the property,or my employe"with wag"as their sole 'NESV RESIDENTIAL ELECTR penuHon,wlll doted work and lheemcturelsnm Intended or offered for Ou e(Sec 7054,Business and Professions Code:The Contradoe.License law does not apply to an owner of property who builds or Improves thereon,and OCC.GROIIIs RES.UNITS dace such work himself m through his own employees,provided that such Improvements arc not intended oroffered(mule.If,howerver,thebuildh g or TOTAL; Improvement lssold within oneyearof completion,the owner-builderwill have tkiLtlirdenof proving that he did rout build orlmprove for purpaaeafule.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN Lj L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE contractors to construct the project(Sec.70K Business and Prof"slots Code: The Contnctm's License Law does not apply to an owner of property who ALTER-DRAIN&VENTWATER(FN Wilds or improves thereon,and who contracts fm such plo - jacts with a FEE SUMMARY mp(Laaorts)Bmnrd P-owu l to the Comrades.License Law. BACK FLOW PROTECT.DEVICE LII am exempt under gen B&P C for this rescan OUTSIDE FELS Owner Data DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N RECEPT p WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y_ N_ ❑I hereby affirm the I have o lmu mte of consent to Dpythe r f or a RECEIPT N certi0mteofWorken'CompensaHonlnsurancema certlfkd copythereof(Sec. 3800,lab C) GAS EA.SYSTEM-1 INCAOUILETS PARK FEE Y N Policy N GAS PA.SYSTEMAVER 4(FA) RECEIPT N Com ny BUILDING DIVISION FEES Certified copy In herebyth the city CRFASHANDUSfRL WASTE INTERCEPTOR PLANC14ECK FEE Certified copy ls filed with the city inspection division. CERTIFICATE OF EXEMPTION FROM WOR KERS' CREAM TRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 100Ff Date RCCeI t# (Thlssecti m.ccd not hem epluted if the permit b furans hundred dollars (g1 m)ca,to..) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N I certify,that In the performance of thework forwhich this permit Is issued, I shall not employ any person in any runner so as to become abject to the WATER SYSTEM/TREATING Workers'Compenutlon Lam of Callfomla.Date PAID z z Applicant NEW RESIDENTIAL PLMB. SQJrT, Date Recei t# Z O NOTICETOAPPLICANT:If,after makingthls Certillcateof Exception,you should become subject to the Workers'Compensation provisions of the Labor TOTAL: N Code,you must forthwith comply with such provisions orthls permit shall be BUILDINGl W > deemed revoked. a F3 CONSTRUCTION LENDING AGENCY SEISMIC FEE I hereby af0rm that there Is a construction lending agency for the perform ELECTRIC FEE O an.of the work for which this permit is Issued(Sec.3071,Civ.C.) TOTAL: V Lurdere Nesse PLUMBING FEE LL F Le.dee.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE O W bmm I.Aifythatlhavereadthlsapplir tl nandoalelhattheaboveinformation a rtcct.I:gree to comply wlthall city and untyordbutecsand Nate laws PFRMTTISSUANCE FEES PAID: >. relating to building construction,and hereby authorise representatives of this f" Z city to enter upon the ahow,menlloned property for Inspection pu rposes. ALTERORADDTOMECH. — (We)agree to save,Indemnify an it keep harmless the City of Cupertino Date Reeel t# agalnstllabNtl ' dgmenta,me sand expect w kh may In anywayaceue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: .galea alit mnsrryence ft gotlhZoi l petmlt. 3 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX Igul of pp cant/Conlr nor 10.4 EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant orfumv building oavpart store or handle haeardou. HEATING UNIT(TO 100,000 BTU) Date Recei t# material as dellned by the Cupertino Municipal Cade,Chapter 9.1 2,and the I fralth and Safety Code Section 255311217 HEATING UNIT(OVER I W,000 BTU) TOTAL: 1 l Yes No Ill theapplicaut m hare Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCJW which emit hararlous air contaminants as defined by the Bay Area Air R` Qu Illy Management District? BOILER-COMP(3HPOR 100,000 BTU) ��kEC (� 4 Yes Q No 3 1 haveread Health oet materIsis nqulrerrc5,25S3under nd 25534.1 of BOD.ER-COMP(OVER 100,000 BTU) �kY Q91 lhsundertandt Health&Safety Code,Sectionsntly have a and 75534.! !NY responsibility that notiff they building does not the which thatb mot NEW RESIDFNIIAL MECH. SQFI'. rvor to Issuance ce of aCtheoccupantof ccupa rtqulremenla which musl6e sued fV1yK prior to luuance ofa Certificate of Occupancy. ��/�aly��1�[ a7 Owner or authoHud agent Date ISSUED BY: � n__r( TOTAL: OFFICE COPY