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23348 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY Building Project Identification PERMIT NO. Building Address;GT23348 were ams: 't" one. PMDPY CITY OF CUPERTINO-BUILDING DIVISION +� C°qr�\rt 0 creee�J` �jLle•_N. APPLICATION*/ P MIT u1'��"-� �Z-I •�/ BUILDING-ELECTRICA PLUMBIN MCAL CATEGORY CONE! ArTe�.1/Fapglr�e�r; LIc.No: b �i,f} G�f QTYEWRIC PET BUILDING PERMIT INFO ' ' FEE mu�l MUM" Address: PERMIT ISS CE �� (y�1I LICENSED CONTRACTOR'S DECLARATION LP Ihereby.ffitaodi..70 ).fDivat I am Bcensed under ftheBuinemadPmfeions hapmr9de,and CES E L JOB DESCRI'ITON it...h lefull7000)a(d effion3olthegualnemandlkolnadoneCode,and my license IB in full{grI end etfed. N©5 Date eCps �t71 Lk.p �/ZZ -1 �) =dl•-111a Date Contndor ARCHITECTS ECLARATION 201. a0 Z I understand my plana shall be used as public records. Vy O 1 A - SQ.Fr.FLOOR AREA $/SQ.FT. G \ �X.00 LV Licensed Pra(emlovl SE TRICAL 6 OWNER-BUILDER D[CLARATION In IAL CIRCNT/MISC 7p, IherehyaffirmlbaU am exempt OLDER the LARATorBLlrense Law for the following reason.(Semon 7031.5_Business and Professions Code:Any city or qqqq roan whlch 1 rmittocomt d,alter,ion pa TEMP.METFRORI'OLE[NST. FBF'@ ty reqs mage prove,demolbh,orre Ir $$$ anystrudure priorto its issuance,also requlresthe applicant foriuch permit to TOWER DEVICES file a signed statement the he Is licensed pursuant to the provisions of t 3 u, Contractor's License Law(Chapter 9(commencing with Section 7000)of EI I- fn SWIMMING POOL ELECTRIC sion3oflhe Business and ProfemlonsCode)orthathefsexempt therefrom and VALUATION < the basis for the alleged exemption. Any violation of Section 70715 by any IOU ILMSWITCHESFIXTURES applicant fora permit aubjedstheapplica.H..dAt pevltyofnet morellun o five hundred dollars($5D0). ❑I as owner of the property, NEW RESIDENTIALELECTR' SQ.FT, STORIES TYPE CONSTRUCTION , p iha ork,a dr my employees t Intended r thea d for ZM compensation,wllldo..nd Prodndthes Code: to Contractor o License eLaw a dale(Sec•apply to an ow and f propsrty ons Code:The builds or unPmve5 License Law q3� does nonsuch tornowner o(p lf or rough whonempoymproveslhereoryach OCC GROUP BPS.UNITS w nd whodoesrntsarekhimrededmattered ough hlsowale.K yecs,prthebrovided thatduch Improvementasold intendneyearfcomordiomthhower-builderwdl have T L gor Improvement bmW whhinoneyearo(campldion,the owner-bullderwW have tItydenofproving Mat he did notbundorimprove for purpose ofsale.). QTY, PLUMBING PERMIT „ FEE FLOOD 7vNE ArN u I,as owner of the property,am exclusively contracting with ilrended PERMIT ISSUANCE �� contractors to construct the project(Sec.7094,Business and Prolamines Code: The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VEM-WATER(EA) bullets or Improves thereon, and who contracts for such ptojeds with a ryfBfactmW licensed pursuant to the Contractors License Law, BACK FLOW PROTECT.DEVICE -FEE SUMMARY 01 am exempt under Sec B&P C for this reason DRAINS FLOOR ROOgA CO �� SANITARY Y_ N_ Owner Date RECEIPT.p WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOLTAX Y_ N_ C31I hereby affirm ns that I have•certificate of consent to self-Insure,ora S RFCEBPf p mAifimteof WorkmCompevatlonlmuranceoraceAlfWmpythereof(Sec. 3800,Lab C) GAS EA.SYSfFM-]INCA OUTLETS PARKFFE Y N Policy p GAS EA.SYSITM-OVER 4(EA) RFCETPT N Com any BUILDING DIVISION' ES ❑pCeruffed copy is heed with the iGREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE is 04JM'407 CcrtiBed ropy V filed with the dty Inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID— •� COMPENSATION INSURANCE $EWER SANITARY STORM EA 20071. CCM 1# (this section need not be completed If the permit b foram hundred dollar ($100)orlem.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N I cem laxe.at N the performance.(the work(orwhich this permit is issued, — I shall not employ any person In any manner so as to became subject to the WATER SYSTEM/TREATING Workees'CompenwBon Laws of California.Date PAID z Z Applicant NEW RESIDENTIAL PLMB, SQ.FT. Date Recei t# Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you sM1wld become subject to the Worker'Compensation provisionsLabor TOTAL: IrW Code,you most forthwith comply with such provisions orthls permit shall be LU > deemed revoked. BUILDING ' CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE .I hereby affirm that there is a construction lending agency for the perform �a ELECTRIC FEE Z ansa of the work for which this permit O Issued(Sec.3097,Civ.C.) O U O Lender's Name PLUMBING FEE LL l= L.ander.Addrem QTY. MECHANICAL PERMIT FLE MECHANICAL FEE �• O W I certifylhmI have read thlsappilcationarui statethe theabove ln(ormallon Iscornet.I agree to comply with all dlyand muntyordlnanosandstatelaws PERMIT ISSUANCE �� FEES PAID: } 4 relating to building construction,and hereby authorize representatives of this N city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MUCH. Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt# V against liabilltled,judgments,costs and expenses which may in any way accrue AIR HANDLING UNIT(TO 10,000 CFM)IXF7AU5'f II00D(W Tl SUBTOTAL: against Id Cityinronuqu molt gran ing of this perm . AIRHANDUNGUNITOv 10,000c CONSTRUCTION TAX gnaturc. pliant/Contractor Dalv~ 411k'10-2� CONSTRUCTION TAX PAID: HAPARDOUS MATERIALS DISCLOSURE Will theapplicant or future building occupant storeor handle hazard.., HEATING UMT(TO 100,OWBTU) Date RCCeI f# material as defined by the Cupertino Municipal Code,Chapter 9.17,and the I lea lth arad Safety Code Section 25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL: ❑ Yea M No Will the applicant or future building occupant use equipment or devices VENTILATION EAN(SINGLE RESID) ISSUANCE DATE which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District) BOILER-COMP OFT'OR 100,000 RTU) 4Y'. No pR�� pp aw.cithehaza nus nuterials requirements under Chapter 6.95 of BOILFR.COMP(OVER 100,000 BTU) P A the California Health&Safety Code,Sections 255OS,75533 and 75534.1 mponbndthal notify the occupant of t e requirhavea tenant that b met NEW RESIDENTIAL MCCH. �,.Ff. APR 1 6 responsibility to notify the occupant.(the mqulremenU which most be met •7�x prior to Lssuanre ofd Cerlifiale ofOavpanry. Lp �� 17 Owner or authorized agent Date - TOT ISSUEDBY' 7IINV .: /e OFFICE COPY