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23776 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES USE BALL POINT PEN ONLY Building Project Identification PERMITNO. Building Address: py— .2-2a R E L&NE CUPMTINO CA %-a14 23776 wnera cats: one: EXF (-((�(( R{(CIQ y� ¢04 748'% 10 CITY OF CUPERTIN0.BUILDING DIVISION ( G°"nRer Le. APPLICATION / PERMIT t0^Vj~`N \ 'n BUILDING-LLECTRICALPLUMBING-MECFIAMCAL CATEGORY CONTROL J - nnr s ELECTRIC PERMIT FEE BUILDING PERMIT INFO PERMITISSUANCE �. y %y 0 LICENSED CONTRACTOR'S DECLARATION ' I iths ion7Oaffinart thatlaiA,i.3.fth.B sinemrlonaof Chapter9(m c APPLIANCES It...I 1.full 7000)of deft n3 ofthe BuslnessandProfessiemCod dmy Gu IO PSC 1' ^ license is in full(qrm and Hfect�^/��A PANQS rR�� 1 �'Y Licence-J�LIc.N U / K Date 1 ContraRor CHITECI'S DECLARATION - 0 1P5 x land tan shall beusN as publlermacds. A'NT'S SQ.ET.FLOOR AREA $/SQ.FF. OCC dz t Licensed Prolesabnal 71GNSE © I�<a. OWNER-BUILDER DECLARATION C C T7I heebyaffirmthatlam exempt from the Contractor.License Law far the ❑ fl.pp follow in aeon.(Section 7MI.5,Business and professions Code:An ct or V 11//a02_Ha Sre Y ty' TERORPOLEINST. -„ FE muntywhlchrequiresapen tmmmb d,alter,lmpmve,dennlbh,ormpalr anystrocture pdorm its Issuance,alsorequlrestheapplleant torsuch permit to POWER DEVICES I r file a signed statement that he Is licensed pursuant to the provisions of the SOu, Contractors License Law(Chapter 9(mrurcncing with Section 7000)of Divi- TI�[J OS Man 3 of the Busionssand Profession Code)or that he is exempt therefrom and SWIMMING FOOL ELECTRIC VALUAO O the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLE7SSWI'ICIIESFa-ru RES /�s/yA pp applicant fora permit subjeatstheapplicanttoa civil penalty elect morethan ' VV(,/ 5A� 16 five hundred dollars(5500). SQ,F(, S7T)WPS TYPE CONSTRUCTION C~C NEW RESIDENTIAL ELFLTR RI,cope as owner ll the property,or my employees with weed as thele sole C G compensation,wllldothewodmfakke.Code:and reh crestud.nded dmfs d for Law '$ q sale(Sec.apply to in owner and f property Code:The Contractors Liceme law (dj B who does apply tornowner of throng hiswho nemor Improve,y.,povided roryuch OCC.GROUP RES.UNITS CG: who dodsuch work hlmxUorlhraugh hlsownemployen,provided that such Improvements are not Intended mattered for sale.If,however,thebullding or 01 bnprovement b cold within oneyearofcwnploion,the mvner-bullderwlll have th,eLixtNen of peaving that he did not build orlmpreve for purpose ofsals.). QM PLUMBING PERMIT FEE FLOOD ZONE APN LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE mniracton to mwtruct the project(See.7044,Business and Professioru Code: The Consomme.License Law don not apply to an owner of property who ALM-DRAIN&VENTWATER(EA) builds or imprwn thereon,and who contracts for such pipicas with a - cgBJpctor(s)Bmnsed pursuant to the Contractor's License Law, BACK FLOW PROTECT.DEVICE FEE SUMMARY LII am exempt under Sea 0 &P C,for this reason `� DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N Owner Data RFAERTX +) WORKMAN COMPENSATION DECLARATION OVRES.PER TRAP t r SCIROOL TA% Y N ❑I heraby affirm that I have•certificate of consent to self-Insure,ora RECEIPT X ceniflateof Workers'Compensationlrauranceeramrtlfkdmpythereof(Sec. 3800,Lab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARK FGE Y N lin,p RECEIPT X GAS EA.SYSCEMAVFR d(EA) any BUILDING DIVISION FEE.. Cenifled copy Is herebyturnlehN. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCI'IECK FEE �s ❑ enified ropy Is(lied with the city inspection division. X V CERTIFICATE OF EXEMPTION FROM WORKERS' CREASETRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA."FT. Date. Rem tp (Thlsse tion need not be completed If the permit a for one hundred dollars (g]UO)ollen.) ENER I mrtlfythat In the performand of the work forwhich this permit Is Issued, WATER HEATER W/VEM/[+l.FiCTR GY FEE Y N— I shall not employ any person m any manner so as to become subject to the WATER SYSTEM/TREATING Workers'Compensation Lawsof Callfomh.Date PAID O Z NOTICAppileaE NEW RESIDENTIAL PLMB._SQ.FT. Date tN Z O NOTICE ca APPLICANT.a after ricers-making this stionlestecf Exemption,you should IXcolrl[subpct to the Worken'Compessatlon provIsloru of the labor TO ~ W Code,you=at forthwith comply wlthsuch provisions orthis permit shall be IL G ss— CC 7 deemed revoked. CL CONSTRUCTION LENDING AGENCY SEISMIC FEE I hereby affirm that there is a construction lending agency for the perform ELECT O anreof the workfor which this permit Is Issued(Sec,3097,Civ.C.) _ V Lenders Name PI I LL f- Lender's Address C?TY.j MECHANICAL PERMIT FEE M20qA ICE OW Iortifythatl haveread thIsapplimtlonand statethattheabove Information a' - It. Iscorrectlagrm to comply with all city and county ordinances and Mate laws PERMIT ISSUANCE FEES } y relating to building construction,and hereby authodse representatives of this - H Z city to enter upon the abovomontloneci property for Wpotion purposes, ALTER OR ADD TO MECH. ate R ] tN V — (We)agree to save,ind omNfy a d keep harmless the City of Cupertino eceP gainer liabilities,judgme h,mks and expenses which may In any wayaccrue AIR HANDLING UNIT(TO 10,000 CFM) UBTOTAL: alrutsald Cirylncons enc of the gra ting oflhls permit. /,$/,� � A .p AIR HANDLING UNIT 10,000CIM) CONSTRUCTI NTAX Sig�naureofA�T/CortmMor— " 6/p ty/9O? EXHAus r How(w/DUCT) CONSTRUCT] TAX PAID: I HAM R DODS MATER IALS DI SCLOSU RE ' Will the applies at or future building occupant store or hand le hazardous HEATING UNIT(70 1 00,ODO BTU) - material as defined by the Cupertino Municipal Code Chapter 9.1 2,and the Date Recei tN Health and Safety Code Section25532(a)7 HEATING UNIT(OVER 100,"BTU) T wWZ%4 ❑Yes Na ..,t,� Will the applicant or ium building occupant use equipment or devices VENTILATION FAN(SINGER REBID) ISSUAN •DATE tot'- which emit havardous air contamma nts as defined by the Bay Area Air 'Quality Management District? BOILER-CAMP Q HPOR 100,ON BTU) ss We ❑No A r thaw rcadthehazardous materials requirements under Chapter 6,95 of BOILER-COMP(OVER 100,000 BTU) the California Health&Safety Code,Sections 25505,25533 and 25534. I um p/ understand that tithe building docs not currently have aionanL that itIsmy NEW RESIDENTIAL MECH. �.FT. "ri p� mpoosibility to notify the occupant of the rNulmments which moat be met J 2 prior to lasuanm of a Certificate of Occupancy. , Mud r�.r,u r/ Ur�I 1 Owner or authoagent Date ISSUED BY: OFFICE COPY