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22583 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY Building Project Identification PEILMITNO. sot Building Address: 225831072 5 PFO!///J//f(/G/�P 9/t �'i( a7IILO neve one: A A 3UVf / /-//LC 7f83K7 CITY OF CUPERTINO-BUILDING DIVISION Contractor's Name: LIc.No: APPLICATION /PERMIT a ( 4 BUILDING-FbL MCALPLUMBING-MLCHANICAL CATEGORY CONTROL N Architect/Englneer. Lie.No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: PERMITISSUANCE ],�0 ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION Herel under provisions erprovivlonsol Chapteoenc APPLIANCESRESIDENTAL JOB DESCRIPTION Ingwith Socti..7000oDii.kn3.fthcBuslnesand ProfnsimnsCd,a.d my license Is In full force and effect PANELS //,D N 'pLlmCas Loc.N Date _Contractor ARCHITECTS DECLARATION 201-1000A,MPS ereuZ I understand my plans stall be used es pubhcrecords. OVER1000AMPS SQ.Fr.FL AREA $/SQ.FT. E V LIcevM Professional SIGNS ELECTRICAL FGGGG y OWNERex exempt DECLARATION f j s� fl n SPECIAL CIRCUIT/MISC L V d Of�' ,CJY Ihereb af0rtn that exem from Contractor's License law for the F following reason.(Section 70715,Buslnen and Professions Code:Any city or AAV51 county which requires a permit to ceratmd,alter,Improve,demolish,orrepalr 7FMP.MhTQR OR POLE INST.any Stiulturo priorto its Issuance,also requiresthe applicamfornuchpernet to POWER DEVICES E-4ellfl �_4r. file a signed statement that he Is licensed pursuant to the provisions of the Contractors Llcerue Law(Cha er9(mmmencin Ith Se ion7000)of Dlvl- VALUATION N R w SWIMMING POOL ELECTRIC O slon3o(the Buslnessand ProfessbvCode)orthat he is exemptthere(mmand < the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS-SWITCHES-FIXTURES applicant fora permit subjects the applicant to a civil penalty of not more than . e hundred dollar%500). NEW RESIDENTIAL ELECTR M1,as owner of the property,or my employees with wages as their sole —SQ-Fr. STORIES TYPE CONSTRUCTION peneation,wnlaothe work anathe structure la not Intended or offered for 5 0 sale(See.7064,Business and Pruesslons Code:The Contractors License law does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP .RES.UNITS who doessuch work himselforthecugh his own employces,provided that such Improvements are not Intended oroffered for sale.It however,thebuilding er TOTAL: 1.s CD improvement bso)d wllhinoneyearolcompletion,the cwner-bullderwill have tK enof proving that he did not build or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN Las owner of the property,am exclusively corstracting with Ilrenaed PERMIT ISSUANCE contractors to construct the project(Sec.7044,Business and Pmfnslov Code: The Contrador's License Law does not apply to an owner of property who ALTER-DRAIN VENT-WATER(EA) Wilds or improves thereon, and who contracts for such ppocts with a of dJaaorti)Brensed pursuant to the Contractors License Law. FEE SUMMARY LII am exempt under Sec, B &P C for this reason BACK FLOW PROTECT.DEVICE Owner Date DRAINSFTOOKRCOF,AREA,COND. SANITARY Y N RECEIPT 0 VRKM COM ENSATION DECLARATION FUTURES.I'EEt TRAP SCHOOL TAX Y_ N p ❑1 he eby affirem that I have a certificate of consent to self-Inwm,or RECEIPT N f, certificate ofWorkers'Compemationlesurance or a certified mpythereof(Sec. GAS EA.SYSTEM-1 INC.40I17LETS PARK FEE Y N 3800,Lab C.) RECEIPT Policy N CAS EA.SVSIFAI.OVER 4(EA) BUILDING DI VISION FEES C. any �Cchifled copy la heed with the cit. GREASE/INDUSTRLWASIEINTFRCE'TOR PLANCHECK FEE ❑cemnea ropy la filed with the city Inspection awiaiom. CERTIHCATTOFO(EMP ION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT DRIC RCC21 t# (fNssectlon need not W completed if the permit Is for one hundred dollars ($I00)orlcas.) NATER HFATERW/VENT/ELECTR ENERGYFEE Y_ N_ 1 certify that lo the performance mf the work fmwhich this pemmt is issued, I shall not employ any person In any manner so asto become subject to the WATER SYS.IEM/TREATING Workers Compensation Lawa o(Call(ornla.Date PAID OZ Applicant NEW RF9DENT AL PLMB. SQFT. P: Date Recel t# Z O NOTICETO APPLICANT,If,after making this Certificate of Exemption,you should become subject to the Workers'Compensation provisions ofthe Labor TOTAL: tY N Code,you at forthwith comply with such provisions or this permit shall be BUILDING FEE W deemed revoked.CONSTRUCTION LENDING AGENCY SEISMIC FEE CL Ihembyaflrmthat there is a construction lendingagency forth,perforrryELECTRIC FEE n Z aoce.fthr workforwhichthla permit is Issued(Sec.3097,CIv.C.) TOTAL: U2 Lerderb Name PLUMBING FEE LLF" Leedees Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE U l certlfythatl have mad thisapplicationand state thatthe above information O W is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID: >. IL relating to building construction,and hereby auflumce representatives ofthis (— Z city to enter upon the aWve-mentioned property for inspection purposes. ALTIRORADDTOMDCIL (We)agree to save,Indemnify an d keep hated.the City mf Cupertino Date Receipt# U against llabillties,)udgemets,coats and expenses which may in any way same AIR HANDLING UNIT(TO 10,ODO CFM) SUBTOTAL: U .gat eatea(d CityAnc apro the granting of this permit. `///!/4Y7/ AIR HANDLING I1h7T(OVER IO,OWCM) CONSTRUCTION TAX / SI at eof Applicant/Contractor Daze E%HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the a pp0cant orf.dum Wilding occu pant store or hand le baeardous HEATING UNIT(TO t 00,000 BTI) Date Recel t# material as defined by the Cupertino Municipal Code,Chapter 9.1;and the I leahh and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: .0 ❑Yes M No Will the applies est or future W ilding occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE which emit hazardous air eve amivnts as defined by the Bay Area Air Plus)A PD Quality Management District? BOILER-COMP GHP OR 100,000 BTU) rN 4Yea ❑❑No have mad the), r ous materials requlremcnts under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) 11/� 1 the Californla 25 Health&Safety Code,Sections 25505,25533 and 34. 1 AUH REM understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT Ill li responsibility to notify the occupant of the requirements which must be met prorwesuanceof.cedificateofoavpancy. NNY1�CU*I% TOTAL: /p Owner or authorlced agent Date ISSUEDBY.. J�Y/r✓L- IA v OFFICE COPY