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24396APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY Building Project Identification Building Address: A 017 owl t P;3OL- . GSA PERMIT NQ, 4 3 9 6 Z lzx_ "�� Qqr SO�ir CITY OF CUPERTINO-BUILDING DIVISION APPLICATION I PERMIT BUILDING-ELECTRICAI.PLUMBINGMECHANICAL APPLICATION SUBMITTAL DAFE Contractor'LMc.No: `yesfk--% **-Ab K Vy\ • CALORY CONTROL# Arch/ed/Engineer. Lk. No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address ❑ ❑ 1:1LICENSED VJ PERIATISSUANCE CONTRACTOR'S DECLARATION I hereby affirmthat l am lkensed under provisions of Chapter9(comma Ingwith Section70f0)of lan3ofthe Busuessand Professions Code, and my license Is In (u0 f Llcen Date Contractor ARCHITECTS DECLARATION I understand my plea shall W used as public records. Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following moson.(Scalon 70315, Business a net Professions Code: Any city or countywhichrequiresapem trocomrmd,alter,Impmve,demolbh,ormpalr anystmu mpdortatrs mance,alsorequl theappilantfasuchpermltto Ole a signed statement that he is licensed pursuant to the provlsloru of the Contractors License Li. (Chapter 9(commencing with Section 7000) of Divi- den 3 of the Bush. and Pre esslons Code) orthat he is exempt therefromand the Wats for the alleged exemption. Any violation of Section 7031.5 by any apphcam fora permit subjectsthe applicant to a civil penalty of not mra than Ove hundred dollars(f5DOL 1, as owner of the property, or my employees with wag" a their sok compensation, will do the work and the structure is not intended or offered for ale (Sec 7094. Business and Professiaa Code: The Contractors License Law does not apply to an owner of property who builds or improves therron,and who does such work himself orthrough hlsown employees, provided that such Improvements are not Intended arotlered forole. If, however, thebullding or Improvement issold withinoneyearofcompldlontheowner-bu0derwill have t1IR.Ilurden of proving that he did not build or Improve for purpose of sale.). L_j L as owner of the property, am exclusively contracting with licensed contractors to m utrud the project (See 7044. Business and Professions Code: The Contractor's License law does not apply to an owner of property who builds or Improves thereon, and who contracts for such p(o)ects with a �qBt[+dor(s)Ilmnsed pursuant to the Contndor'a License Law. LJ I em exempt under Sec B k P C for this reason APPLIANCES -RESIDENTIAL JOB DESCRIPTION PANELS UP TO 2011000 AMPS OVER 1000 AMPS SQ. FT. FLOOR AREA , f/SQ. FL. SIGNS ELECTRICAL SPECIALCI9CNT/M15C TEMP METER OR POLE INST. POWER DEVICES SWIMMING POOL ELECTRIC OUTLETSSWI7CHF5HX'1'URFS VALUATION NEW RESIDENTIAL ELECTR gQd'f STORIES TETE CONSTRUCTION TOTAL: QTy. PLUMBING PERMIT FEE OCC.CRON' RIS UNITS FLOOD TONE APN PERMIT ISSUANCE ALTER -DRAIN It VENT • WATER (EA) FEE SUMMARY BACK FLOW PROTECT. DEVICE OUTSI Do FEES DRAINS FLOOR ROOF, AREA, COND. FIXTIJRIES PER TRAP SANITARY Y N RECAP[ Y Owner Date WOR KHAN COMPENSATION DECLARATION [:]I hereby affirm that I have a certificate of consent to self -Ince, or a mAifimteofWorkers'Compematimlauranmoracenifled copythereof(See MOO, Wb C.) Policy p SCHOOL TAX Y_ N R��.» CAS FA.SYSITIDI-1 WC.40lITLETS PARK FEE Y N RECEIPT # GAS EA. SYST[M-0VER 4 (EA) Com any BUILDING DI VISI ON FE ES Certified copy Is heed with the hed. CertBkd copy Is flied with the dty inspection divider. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (rhlssee lon need not be completed lithe permit le forone hundred dollars ($100)rtifytJ (certifythato anypehe omunaoflhewak for to which mbjectmit is to therd, 1 ore not employ any person In any manner at u to become subject to the become Worken' Compensation laws of California. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation pmvkionsof the Labor Code, you awn forthwith comply with ouch provisions orthb permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there b a construction lending agency for the perform -TOTAL: anm of the work for which this permit is Issued (Sec. 3097, Civ. C.) Lenders Name Le.deea Addreaa I certve llythatI haread ihbappficationand state that theabove Information Is correct.I agree to comply with all city and county ordinances and nate law. relating to building ronstroction, and hereby authorlae representatives of this city to enter upon the abovo-menrianed property for inspection purposes. Me) agree to save, indemnity an d keep harmless the City of Cu No loo agahut liabilities, Judgment,".and expenses which may in any way amus ago lost old City in ronsequence of the grant Ing of this permit. gnature of Applicant/Contractor Date HAZARDOUS MATERIALS DISCLOSURE Will theapplicau or future building Fortson. or handle haaardous material as defined by the Cupertino Municipal Code Chapter 9.12 and the I lealth and Safety Code Section 25532(a)? ❑ Yes U No Will the applicant or future building occupant use equipment or devices which emit hanrdous air contaminants as defined by the Bay Area Air Yality Management District? Yes d No have read the haze ossa rnaterials requirements under Chapter 6.95 of the California Ilealth h Safety Code; ged ions 25505, 25533 and 25534. 1 undwatanl thatItyto fthe fybut the ing doesromps or ofnot erequire meat which u odersibllitymnet ifythe occupant oftherequlyhave whichmeat it met that it met prior to Issuance of a Certificate of Ocetpa racy. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK PEE PAID Date RCCCI I# GREASE TRAP SEWCR-SAMTARY-STORM FA. 2001T. WATER HEATER W/VENT/ELEC.I.R ENERGYFEE Y N — PAID Date Recei f# - WATER SYSTEM/TREAITNG NEW RESIDENTIAL PLMB. _SQFf. TOTAL: BUILDING SEISMIC FEE ELECTRIC FEE QTY. MECHANICAL PERMIT FEE PLUMBING FEE MECHANICAL FEE PIRMITISSUANCE FEES PAID: ALTERORADDTOMECH. Date ReCeI I# AIR HANDLING UNIT (TO 10,000 CFM) SUBTOTAL' AIR }iANDWNC UNIT (OVER IO,000CFM) CONSTRUCTION TAX EXHAUST HOOD M/DUCT) CONSTRUCTION TAX PAID: HEATING UNIT (TO 100,(00 BN) Date RCCCI t# HEATING UNIT (OVER 100,000 BTU) TOTAL: VENTILATION FAN (SINGLE RESID) ISSUANCE DATE �� ®/�T Cll t U>6_ llY ISSUED BY:�"'T BOILER -COMP DHPOR 100,000 BTU) BOILER-COMP(OVER 100,000 RTU) NEW RESIDENTIAL. MCCH. SQ.FT Owner or authorised agent Dateur/ �j OFFICE COPY