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23173APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Pru'et Identification PIB(MIT NO. Building Addrc,,:17K AL <�7 3 23173 e7 QJ �( � CITY OF CUPERTINO-BUILDING DIVISION APPLICATION / PERMIT BUILDING-ELECTRICAI.PLUMBING-MMHANICAL A DAM Conaator'a Na : G�5 S .N CATILORY CONTROL N Archltet gineee Lie. N. QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address I'FAhITISSUANCE ❑ ❑ ❑ LICENSED DECLARATION ED CONIEACder Ihereby that pr ctior,mthatl am licensed oftheBrleassaonaof Chapler9(commrnc InenseI Section force of Dl effect ofthe BuAlvsand Profeasl.v Code, and my license b In full (arca and effect APPLIANCES -RESIDENTIAL JOB DESCRIPTION PAN©S uChn A) \► ��1'� D.t .rt Date Contractor U2 TO 200ANTS 1 2011000 AMPS ARCHITECPSDECLARATION I understand my puns ehaB be used n public records. OVER1000AMPS h u ®SQ. RAAG S/SQ. FT. Licensed Profeni.vl ' OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contract.e. License Law for the SIGNS ELECTRICAL -- T R SPECIALCTRCUIT/MLSC TFMP.METFR OR TOLE INST. following rezwn.(Setlon 9031.5, Business and Profanlons Code: Any city or county which requires a permit tocont ,tru, alter, improve, demolish, cempair '� any stvcwm Peoria its issuance, also requiresthe applicant forsuch permit to file a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES SWIMMING POOL ELECTRIC OUILE S-SWITCHESFIXTIIRES Contractors License law(ChaEtter 9(wmmendng with Section 7000) of IRA. Alan 3 ofthe Bustnessand ProfessionsCode) orthat he Isexempt therefromand the basis for the alleged exemption. Any vi.latlon of Se tion 70315 by any appBcan! for A permit subjects the appilcam to a civil penalty of rat mare than VALUATION 1 L OQ /� NEW RESIDENTIAL ELECTR SQ.FT. five L a sr owner of the pro ❑I,as owner.( theproperty,orhe employees with wage as their sole STORIES =CONSTRUCTION the work and structure ls Intended or offend for ole &c. 0Kion, Bu iness.do dole (Sec 704X, sf.l. C an and PMemlov Cada The Comraciols Ucecte law to ow don rat apply roan owner ofpropertywho bulids who dvementsa such mpor thercer, that and his own e. that such OCC.GROIIP RFS UNITS TOTAL: improvements arerat Intended If,ho eprovided not ilf ntended for dale.ILh the uilI ser-buildever, Improvement hsoldwuhln one ycarofcomplMion,Meowner-bulWerwill have earofco have thrden of proving that he did not build or Improve for purpose of Asia.). eL1, as ..or of the property, Am exclusively contracting with Ilcenxd contractors to covtmt the project (Sec 70K Business and ProfessionsCode: QTY. PLUMBING PERMIT FEE FLOOD ZONE APN PERMIT ISSUANCE The Contractor's License Taw does not apply to an owner of property who bulldts s or Improves thereon, and who contracts for such p(ojewith a �gtSfator(A) licensed pursuant to the Contractor's License Law. nal am exempt under Sec. B h P C for this reason ALTER -DRAIN &VENT -WATER �A) FEE SUMMARY BACK FLOW PROTECT. DEVICE OUTSIDE FEES DRAINS FLOOR ROOF, AREA, COND. FIXTURE_$ PER TRAP SANITARY Y_ N_ RECEIT N Owner Dae WORKMAN COMPENSATION DECLARATION I hereby affirm that I have a rtificaof consent to self -insure, ora [:]Icete certificate of Workers Compensation Insurance ,orAa mtlflad copy thereeffSec. p C.i �O D Polis Lab C.) 0 y0 ��, SCHOOL TAX Y_ N_ RECEIPT N GAS. EA. SYSTEM -]INCA OUTLETS PARK FIB: Y_ N_ RECEIPT GAS. FA, SYSTEM -OVER N (EA) Coliq Cenv /t/y/ BUILDING DIVISION FEES 1Cerufied copy Is hereby fumlahM. 5 .Q fled copy is filed with the city Inspection division. CREASE/[NDUSIRL WASTE INTERCEPTOR PLANCI-IECK FEE GRFASE7RAP CERTIFICATE OF EXEMPTION FROM WORKERS' PAID COMPENSATION INSURANCESEWER-SANITARY-STORM 111.sean need rat be compited Ithe permit isfor one hundred dollars ( d EA. 200FT. Date Receipt# WAHRHFATFRW/VFNT/FI TR ENERGY FEE Y N_ (5100)rel..) 1 ratify that M the performance of thework forwhich this Fords i, (awed, WATER SYSTEM/TREATING I shall not employ any person In any tanner w u to become subject to the Workers' Compensation Laws ed California. Data PAID NEWRESIDENTIALPLMB. SQ.FT. Applicant Date Recei t# NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor TOTAL: BUILDING FEE C.dgy.0 mu at forthwith comply with,ech prevkMvarthis permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE I hereby affirm that there is a construction kmdingagency forthe perform ante o(the work for which this permit Is issued (Sec. 3097, Clv. C.) Lender'.Name Lender'.Address I mtifythat I have read thlsapplicationand statethattheabove information corret. I agreeto comply with all city and county ordinances and state laws TOTAL: ELECTRIC FEE PLUMBING FEE QTY. MECHANICAL PERMIT FEE MECHANICAL FEE PERMITIS5l1ANCE FEES PAID. relating to building construction, and hereby authorize representatives of Nb city to enter upon the above-mentioned property for inspection purpose,. (We) agree to save, indemnify an d keep harmless the City of Cupertino agaWt liabilities, edgmin 8, on rad expenses which may In any way accrue ALTERORADDTOMECH. Date Receipt# AIR HANDLING UNIT (T010,000 CFM) - SUBTOTAL: against G locos a of th<granun o(thi, permit AIR HANDLING UNIT (OVER 10000CM. CONSTRUCTION TAX Sinamm of Appliraryt/j on trader ` Data D(HAUSI HOOD(W/DICT) CONSTRUCTION TAX PAID: HA RDOUS MATERIALS DISCLOSURE HEATING UNIT (TO 100,000 BM Will the applica.,future building occupant store or ho rad le hazardous material a, dcfi neePby the Cupertino Municipal Code, Chapter 9.1 2, and the Data Recei t# HEATING UNIT (OVER 100,000 BM TOTAL. Health and Safety Cade Section 25532(a)? r-1 Yes �No VWf1LATION FAN (SINGLE RESID) CE DATE JANardous f5 Will the applicant or ture building occupant use equipment ordeviccs which cont harair contaminant, as defined by the Bay Area Air Quality Management District? Yes QNo have read the haaaraous materials requirements under Chapter 6.95 of II JAS 09 1992 BOILER -COMP OHP OR 100,000 BTU) BOILER-COMP(OVER im000 BN) the California I lealth k Safety Code, Sections 25505, 25533 and 25534. I understand that lithe building does not currently have a tenant, that it is my responsibility to notify the occupant of the regWreme,nta which at be min prior to issuane, of a Certificate of Occupancy. CITY Ur laul-rnIImI baalllaal ISSUED BY: NEW RESIDENTIAL MECH. SQ.FT. Owner or ..Modred agent Data TOTAL OFFICE COPY