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23578 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PERMITNO. B°Ilding Addreau 23578 nen.roome: ,C n^ APPLICATION SU89=DATE SMU CITY OF CUPERTINO-BU NG DIVISION C a 114111 LL Lk.No APPtICATlO I PERMI —1, Architect/En v�[� BMLDINGELECTRIC PLUMBINGMECHANI AL CATEGORY CON7y0 glroer. Lk.N. o QTY TCPERMIT .E BUILDING PERMIT INFO Address: ANCE ❑ ❑ LICF.NS ED CONTRACTOR'S DECLARATION I hereby affifirre7000).[am gee 3.fth.B.and r i. .ndl m Chapwssions 9(mmmen CESRESIDE L JOB DESCRIPTION ingwitASection7000)o(Dleffixt ofthe,uslnessanld ProleaslomCodc,andm Ilmnse la In fu o d d(ect rANEIs CR` Llmnle Clj{LLIC Date • • Contractor � _]L ARCHITECTS DELLA ATION 201 1000 AM rsO zC I understand my plans shall be used as public records OVER 1000 .SQ.FT.FLOOR AREA $/SQ.FT. (0 Licensed Professional SIGNSEI.FGTRI �6 OWNER-BUILDER DECLARATION SPECIAL CIR T/M1SC p, q Ihereby affn,thal l am exempt from the Contractor's License law for the OO ❑ following reason.(Se tion 70315,Businessand Professions Cade;Ary cityor TEMP.M OR POLE INSI. P e' cmntywhkhmquimapermitlommtmdalteplmpmwdemolleh,orrepalr '� a nystmdumpriortotts amealsorequimtheappUaAtfwsuchper tto �a Ole a signed statement that heprovisionslicensed pursuant to the provisions of the POWER DEVICES ^ ^ n O Contractor'.License Law(Chasser 9(weremcdn ithSection 7000ofDivi- Mon 3 of the Business and Profero seioCode)or that he b exempt therefrom and SWIMMINGPOOL ELECTRIC •-- VAEU41ON the basis for the alleged exemption. Any Woleetion of Section 7031.5 by any OUTLETSSWITCHESFIXTURFS ❑ applicant fare permit subjects the applicant to a civil penalty a not mare than 1� I � ,�0 R five hundred dollars(SM. NEW RESIDENTIAL ELECTR .FT. nL as owner of the property,or my employees with wages as their sole TYPE NSTRUCTION � a compensation,will do the work and the stmture la not Intended or offered for DATE yy ❑ sale(Sec.70,14 go.],and Professions Code:The Contrecto/s License Taw t}s$ don not a pply to an owner of property who builds or Improves thereon and OCC.GROUP' RES.UNITS who doessuch work himself or through hlsown employees,provided that such Improvements are not Intended oroffered forests.If,hmevep thebutiding or TOTAL: Improvement bsold within oneyeamfcompltiom the owner-bullderwill have ' tt%_Iurden of proving that he did not build or improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE FLOOD TONE APN LJ L as owner of the property,am exclusively contracting with licensed contractors to construct the project(See 70K Business and Professions Cade: IsFRMFf I.SNANCE The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) builds or Imroe pvthereon, and who contracts for such pta)eta ALTER- DRAIN a FEE SUMMARY �q➢t�+dor(s)licensed pursuant to the Contractor'.License Law. BACK FLOW PROTECT.DEVICE TTI am exempt under Sec B& P C for the. ..a DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N_ • Owner Date RECEIPT p WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y N_ ❑I hereby affirm that I have o Imeura to of consent to opytheurc,(Sa _ RECEIPT X 3certif800,tteof Workere Compersatlon lrsunnreara rertl(led copythemo((Sec. GAS F.A.SYSTEM.11NC.4OUTLETS PARK FEE Y N 3Xlic lab C3 RECEIPT N Policy X GAS EA.SYSTEM-OVER 4(EA) Com any BUILDING DIVISION I'E[S Certified copy e.hereby furnished. GREASE/IN!DUSTRL WASTE INTERCEPTOR PLANCHECK FEE Certified copy b filed withh the e cicity Inspection division. ✓ I CERTIFICATE OF O(EMPFION FROM WORKERS' CREASE TRAP PAIL/ L�aA�1 COMPENSATION INSURANCE SEWER-SANTFARY-STORM FA.200177. `—S��1iIt2r�/—�•t Recei [# (fhlssedion need net be completed If the permit b forone hundred dollen (SIOO)ortessJ WATER HEATER W/VENT/ELFCTR ENERGY FEE Y N I certify that(.the performance of the work for which this permit is issued, I shall not employ any person In any manner.as to become subject to the WATER SYSTEM/TREATING Workers'Compensation Laws of California.Date PAID ZZ Applicant NEW RESIDENTIAL PIMB. SQFf. O Date RET!R! NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Workers'Compewt Ion provisions of the Labor TOTAL: N Cod,you.9 forthwith comply with such provisions orthb perretshall be •E W j deemed revoked. BUILDING CONSTRUCTION LENDING AGENCY SEISMIC FEE [l G Ihembyaffnrtnthat there Ise mnstmdlon lending agency for the perform ELECTRIC FEE M Z once of the workfor which this permit Is Issued(Sec.3097,Civ.C.) TOTAL: CUS Lender's Nems PLUMBING FEE LL ~ Lendefs Address. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE OW Icertlfy that[haveread this eppllationaM statethattheaboveinformation 1 Is correct.l agree to comply with all city and money ordinance andstatelaws PERMIT ISSUANCE FEES PAID: >_ 0- to building comtrutlon,and hereby authorise representativesaflhb (— N city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. ? (We)agree to save,Ind emnlfy an d keep harmless the City of Gu pert Ino Date ReteiPt# V against liabilities,P dgments,costs and expenses which my In anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: against said City In consequence of the granting of this permit. NR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX Signature of Applicant/Contractor Date FXHAMHOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZAR DOLS MATERIALS DI SCLOSURF. Will the applkacat or future building occupant store or hand Is haxardous HEATING UNIT 100,0008TU) Date Rete' material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code Section 25532(.)7 HEATING UNIT(OVER 100,000 BTUs TO I�I Yes MN. Will theapplinnt orfeture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE which emit hannious air contaminants as defined by the Bay Arca Air Qu allty Management District? BOILER-COMP©Ida OR 100,000 BTI) 4Y.a ❑No p havemadthehazardousmaterials requirements under Chapter 6.95of BOILER-COMP(OVER 100,000 BTU) the Californla Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that lithe building does not currently haveatenant,that It Is my NEW RESIDENTIAL MECH. SQ.FT. JU�y2 resporeeibllilyto call thea pant I he requirements which must be ret rj las rior to sea ofd Ceres ret panty. CII v sJ �a /days �• �Q'��G-9 ��y..yUyf• r. Owns or out agent Date ISSUEDBY:V 1,vu TOTAL: OFFICE COPY'