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23005 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Pm ect Identification PERMIT NO. [ 2 L Building Address: sY� R - 23005 `�1/i b� �R��Fr re amp: one: q CITY OF CUPERTIN0.BUILDING DIVISION contan�ryName: Lie.No: APPLICATION / PERMIT •. Architect/Engineer. Lie No: BUILDINCIMECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL,N QTy ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: T PF]1hIITISSUANCE El ❑ ❑ LICENSED CONTRACTOR'S DECLARATION I hthat I amduMEner 9APPLIANCESRESIDEMIAL �]O�B DESCRIPTION InthSedion7D0)ofOiv.f..3 (TheBusinemandProfe.sionsCode,and my licenseis In full farce and effect. PANES Llcena Cion Llc.N Date Cmomc car ARCHITECTS DECLARATION 201-1000 AMPS ❑�u re Zp l understand my plana shall be used as public mmde. OVER 1000 AMPS ///SSSQ.FT.FLOOR AREA $/SQ.FT. Ely�j Licensed Professional SIGNS ELECTRICAL �IA o ' OWNER,B MILDER DECLARATION ; t� 1... fff�� 1`n] SPECIALCIRCUIT/MISC Z0 2 I hereby a(flnn that I am exempt fromthe Contractor's License Iaw for the A oo following reason.(Section 70315,Buslneaand Profeaslons Cade:Mycity or ` ) ��/� O Z" TEMP.MEM OR POLE INST. F� county which requlresapemdttomtutmn,alter,the applicant gdfr such permit any structuretatemenIto lat he I.also censed ensuing t the pro mahpermlte POWER DEVICES E -G 30 Ole a signed statement that he b licensed pursuant to the Ion 7000) of the — 0� Contractor's Licerue law(Chepter9(wnurcndng with Session 70W)o(Dlvl- SWIMMING POOL ELECTRIC don3ofthe lhodeassand ProfeaimaCed0 orthat he b exempt therefromand VALUATION < the bub for the alleged exemption. Any violation of Section 703IS by any OUTLETSSWITCHFSFTXIURES O apphmnt fora permit subjects the applicant to a civil penalty of not more than five hundred dollars($500). I,as owner of the property, NEW RESIDENTIAL ELEC7R SQ.Fr. SPORIES ]YPECONSTRUCTION 1^n p party,or my employees in with wages there sole will do the compensation,Business and k fenlond Code: he Contractors ontor actorended or License Law O sale(Sec. pply to Businessand property Code:The Contractors ves hereon Law whododoes tappty torn owner offprough his wn em erlmproovided that such OCC.CROUP RIS.UNITS whodoeasuch are not himself or ed orough hlsowne.If,ho employees,provided thrtsu ng or ag _� improvementsarenot Intendedearofcudfor Bale.theower-Milder ill have Improvement laeatdwlthln oneyearofeomptnWn theowner-bulWerwlll have IlVLLmlen of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD TONE APN LJ L as owner of the property,am exclusively mntncting with licensed PERMIT ISSUANCE contractors W costruct the project(Sec.701q Businea and Profealora Cade: The Contractor's License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) builds or improves thereon,and who contracts for such pipjens with a c7faIactor(s)Hennaed pursuant to the Contactors Ll¢nse,Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY L�I am exempt under Sec B k P C for this reason Owner ale DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N D WORKMAN COMPENSATION DECLARATION RECEIPT p FDnURF_S.PER TRAP SCHOOLTAX Y N C31 hereby affirm that I have a mniBcate of content to sel4irsom,n a RECEIPT Y artlBateofWorken'Compemationiraunnmoramnlfl mpythereof(Sec. 3800,Iab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N Policy M CAS EA.GYS'1'EN-0VER 4(PA) RECEIPT N Co y BUILDING DIVISION FEES an ,ffCenlBed copy b hereby furnished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANC.HECK PEE ❑Ccnlfled copy Is filed with the city Inspection division. _ CERTIFICATE OF UEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SF ER SANITARY-STORM EA 200F1. Date Recei t# (fhlssenion need not be completed if the Permit b for ane hundred dollars (510 Iartinilca.) NceELFGfythat the performano(thework forwhlch this permit is isWATE(HEATERW/VFNT/ TEL ENERGY FEE Y_ N_ I shall not employ any person In any manner n as to become subject to the WATER SYSTEM/TREATING Workers'Compensmcan Lawsof California. DataPAID O Z Applicant NEW RESIDFNUALPLMB. i t# �.Fr. Date Rece Z O NOTICE TO APMICANT:If,oftor making this Certificate of Exemption,you Fshould become subject to the Workers'Compensation provisions of the Labor TO'T'AL: N Cade,you must forthwith comply with such provielom orthis permit shall be LU > deemed revoked. p UILDING FEE p CONSTRUCTION LENDING AGENCY SEISMIC FEE IL IhembyafRrmthat there is a criatrunion lending agency for the perfarm- ELECTRIC FEE Z once of the workfor which this permit b Wued(mc.3097,Civ,C.) TOTAL: (,) O I,ander.Name PLUMBING.FEE LL H lander.Add reg QTY. MECHANICAL PERMIT FEE MECHANICAL FEE O W Icertifythat l have read thbapplatbnand statethat theabove Information C bn caect.I agmatocomplywlth allcityand muntyordlnancesand nate laws PERMITISSUANCE FEES PAID: >. relating to building construction and hereby authorize representatives of this F— Z city to enter upon the above-mentioned property for in.penbn purposes. ALTER OR ADD TO MECH. — (We)agree to ave,Indemnify an d keep harming the City of Cupertino Date Recei t# - agacnetllabRlOes,judgments,consand expenses which may In anywayarcrue AIR HANDLING UJIT(TO 10,ODOCFM) SUBTOTAL: aga Wt said City In consequence of the gra.ning o"".permy. AIRHANDIING UNIT(OVER 10,"CFM) CONSTRUCTION TAX Igmt sof Applicant/Cantractar Dak - EXHAUST I100D(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE WllltheappEa of or future building occupant store or handle havardous I RATING UNIT(TO 100,000 BTU) Dale material as defined by the Cupertino Municipal Code,Chapter 9.1$and the Reeel t# Iiezlth and Safety Code Section 2SS32(a)) HEATING UNIT(OVER 100,000 BTUs TOTS ❑ Yea No Wlillhe a ppllcant or Nm building occupant use equipment or devise VPNTILAT)ONFAN(SINGLERFAD) ISSUANCE DATE which emit hazardous air contamioante as defined by the Bay Area Air App Quality Management District? BOILER-COMP OHPOR 100,000 B 4 Yr'a �No haveread the ID hazar oar.materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,CM BTU) p1�1/ 19 1991 the California Health k Safety Cod,Sentara 25505,25533 and 25534.1 NOV understand that if the building don not otimotiy have a tenant,that it b my NEW RESIDENTIAL MEIN. SQ.FI responsibility to notify the occupant of the requimmorts which most be met Nth I((VU prior to Issuance of a Certificate of Occupancy. GITy Uf CU Owner or authorizad agent Date ISSUED BY TOTAL: OFFICE COPY