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23337 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Pru'ed Identification PERMIT NO. BuildingAddress: YO ©^-1/ Q' 0 - 23337 •' wner r amone. APPLICA IION SUBMI I I AL DA pE• S �- �6- CITY OF CUPERTINO-BUILDING DIVISION Cootr is Name: t� ;Ay3 - APPLICATION /-PERMIT } I Yc7 J1S BUILDING-ELECMCA�ML BINE-MECHAMCAL CATEGORY CONTROL M _ ArtMtact/Engine<r. Lk.No: ' QTY ELECTRIC-PERMIT FEE BUILDING PERMIT INFO Address: PERhITISSUANCE E. ❑ ❑ LICENSED CONTRACTOR'S DECLARATION Ihercb affirm that l am licensed under provisions of Cha 9(commm APPLEANCESRESIDENTIAl Y P pier • JOB DESCRIPTION in imst i Ee 41all f.me and e f ect.3ofthe Buslnmand Profession.Code,oras my • license Is In fuI(ora and dfM. PANELS , 1 Lt...Clam Lic.p KI Data Contractor ��/I. �r ARCHITECTS DECLARATION 201.1000AMPS QZ Iundergand mypbashallbeused as publiereeorde OVER 1000 AMPS SQ.FI.ILOOft AREA f/SQ.FI. z Licensed Professional SIGNS ELECTRICAL O 6 OWNEReBUILDER DECLARATION �,� P U T S b`i]q SPECIAL CIRCUIT/M]SC 7t.., owing rasormttuton 7031mpt/mms and Professions Code: LawAny drtheyer - followingichm.(Section7 tto Businessand Professions Code:Anycityor OF 1.., TEMP.METER OR POLE INST. �Q countyctore requitesaperMttorooreclt,alteheapmve,demoWh,armit I any atructurc priortoistatement Issuance,also sed pursuartt thepcant or uch inions of tto POWER DEVICES file a signed statement that he V licensed pursuant to the provisions of the TE Contractor's Licerue Law(Chapter 9(commencing with Section 700D)of Divi. SWB.IMING POOL ELECTRIC VALUATION O sion3 of the Buslnmand Profmloa Code)brthat heb cam therefromand 5 the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWITCHESFIXTURES . EEE555 appBant fora permit subjeRatheapplicantloa civil penalty clout marethan five hundred doll..($500). NEW RESIDENTIAL ELECTR SQ.Fr. STORIES TYPECONSTRUCTION j.. ❑eiasowneroftheproperty,ormy employees withwagesatheresole k7a sampSce.7Eonwilldothe,Business and kand lhes Code: Contict ended License ed for Law $�O sale(5ec.701d,Business and Professions Code:The Contnciore Llceae Law ' $$ docs not apply to an owner of property who Wilds or improves therms,and OCCGROUN RES.UNITS who does such work himselforthrvugh his own employees,provided that such improvements are not Intended or offered for sale.If,however,the building or TOTAL: Improvement bwldwithin oayeamfcompldiogtheowner-buBderwlll have . t burden of proving that he did not Wild or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN _ I,as owner of the property,am exclusively contracting with licensed pFRMITLASUANCE contractors to construct the project(Sec.7044,Businessand Profesalom Code: The Contractor.License Law does net apply to an owner d pmperty who Wilda or Improves thereon, and who contracts for such pWoets with a ALTER-DRAIN&VENT-WATER(EA) . co,EdMda(.)Bau nsed punuano the Contnctor'e License Law. - FEE SUMMARY U 1 am exempt under Sec. 4d B &P C for this reason BACK FLOW PROTECT.DEVICE Owner Data DRAINS A,FLOOR ROOF,ARECONED. SANITARY V N_ - WORKMAN COMPENSATION DECLARATION RECEIPT a [71 hereby affirm that I have a artlBote of consent to self-Insure,or a FIXTURES.PER TRAP SCHOOL TAX' Y N 3800,ab of Worken'Compeaallon Imuran.or a artifkd copythereof(Sec. RECEIPT X 3800,Lab C.) /{s� yv//�,���A]ryry -T GAS EA.SYSTEM-1 WC.40IJTLE7S PARK FIE Y_ N_ Policy$ I xeX;ZR 4 / ��JC RECEIPT# •' Com any GAS EA.SYSTEM-0OVER (EA) BUILDING DIVISION FEES C. ffieampybhercby(urnlahed. GREASE/WDUSIRL WASTE INTERCEPTOR - PLANCHECK FEE ' entified copy Is filed with the city Inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWER- STORM-STORM EA.200FT. Date RCCeI f# IThis section need not be completed ff the pem t b forom hundred dollars (SIBO)orlean) WATER I-(EATER w/VENT/El.MTR ENERGYFEE Y N I certify that In the performance of the work forwhich this permit la issued, I shall not employ any person In any manner so as to become subject to the Worken'Compenmtmn Gwso(C+Bfmobi. Date WATER SYSTEM/TREA77NG PAID O Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Rete] t# Z O NOTICE TO APPLICAM:If,after making this Certificate of Exemption,you N should become sub)eci to the WorkersCompensation provisions of the LaWr TOTAL: _ Code,you most forthwith comply with such provisloa or this permit shall be 6UILDING FEE - W > Beamed revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE M Ihercbya(firm that tharebacoatmctlon kntlingagenry forth.perform - O ELECTRIC FEE 7 Z ance ofthe workforwhlchthls permit is Lssued(Sec.3097,Clv.C.) O 0 Iender.N.me PLUMBING FEE IL I— Lender.Address QTY. MECHANICAL PERMIT FEE MECHANICALFEE O W Icertifythat I have read thisappllama tion and gate thatthe abov<information - _ bcormet.I agreeto comply with all cityand county ordinances and gate laws PERMTTISSUANCE FEES PAID: } W rxIMingtobuildmgcoatruol..,and herebyamhortrempresemativesofthls ~ Z city to enter upon the abov&mentioned property for Wpectonpurposes. ALTERORADDTOMFCH. ago WDate P Retelpt# (We)agree to .comfy an d keep harm] the City of Cupertino V Turetlhbillt ,pg d nt.,cosa.dex anw hnay In any ayamue AR HANDLING UMTCf010,000 CFM) SUBTOTAL; tsal 1 usequencedithe, Ing Ie permit AIR HANDLING UNIT(OVER l0,000CFM) CONSTRUCTION TAX Slgatu pphcant/ tr ate EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: „ HA US MATIiR1AL5 UISCLOSL'RE , Will theapplla tum building occupant store or h`an Ie harardou. HFATING UNIT CIO)ODODO BTU) Date Retei t# nmerlal as defined by the Cupertino Municipal Cale,Chapter 9AZ and the Health and SafetyCode MN. HEATING UNIT(OVER 100,000 BTU)• TOT L• QV F1Yea L_I No WBltheappllant or future Wilding ucrupant useequlpment ordevices VENTILATION PAN(SINGLE RESID) - ISSUANCE DATE which emit harardous air contaminants as defined by the Bay Area Air Qu ality Ma agement Diulo? - . , BOILER-COMP OHP OR 100,000 BTU) - -Taz Yes Na PAID Maur,read the bar ous matelots rcqulrcmenls under Cha pier 6.95 of BOILER-COMP(OVEt 100,000 BTU) •the California I lealth&Safety Code,Sections 25505,25533 and 25534. 1 - uMcrstand that if the building does not currently have a tenant,that it is my NEW RESiDFAL MECH. - SQ.FT. Prate res ` ponsibility to notify the occupant of the rcqulrementa which twat be met r a IIJ .Vx 199 prior to houa nm of a Certificate of Ocxu pa nry. - a CI7 rfc r. M, n A Owner or authorizeIOTAC: d agent Date ISSUED I1 . OFFICE COPY ^f(