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23441APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY Building Pro en Identification Building Address: PERMITNO, 45 ��. 23441 Photo: ^S e CITY OF CUPERTINO-BUILDING DIVISION APPLICATION I PERMIT Z 2 Contractors Name:LIc. N. BUILDING-ELECTRICA417LUMBING-MECHANICAL CATEGORY ' CONTROL Architect/Enginrer. Llc No: Q1Y ELECTRIC PERMIT FEE BUILDING PERMIT INFO AddmasPERMITISSUANCE �� D LICENSED CONTRACTOR'S DECLARATION Ihereby affirm that l am licensed under prmlalons of Chapter9(commune. logwItbIntion 7000¢andvisto afthe Bugneuand Proleatlons Code, and my If...iSection to. and APPLIANCESRESIDENTIAL /A JOB DFSC1&UL17I0N— PANELS License Clan Lk.N N✓✓�O/�r Date Contractor UP TO 2DOAbTS 701-1000 AMPS ARCHITECPS DECLARATION I understand my plansshall be used as puddle record& OVER 1000 AMPS SQ. FT. FLOOR AREA $/SQ. FT. SIGNSELECTRICAL Licensed Professbvl SPECIAL CIl2CUIT/MISC OWNER -BUILDER DECLARATION Ihereby...(haton 7031mp.gresseContractor's Llcenre Lawton.¢ (ountyw ich req lama pe7 tto,Bmtl caIt Pro(emlov Cmle h ydtyor muntywMch requitesspermit e,ronstmct,alter,Improve,aemolbh,ermit to Issuance, cubo sed ires anto thetfor aionsch of to any.signed statemprior to ent that pursuant it the Pon 7") of the Bic a signed statement that he b licensed (commencing Contractor's3 ofthLicense usloes]aw rofessCha er9(commencing with exempt of vi- slon3o(the Buslneuand Professions Code)orthat hebexempt therefmmand and the bash for the alleged exemption. Any violation of Section 7031.5 by any nt applicant for a permit subjects the applicato a civil penalty of nM more than g L E D l �� -1� �/ TE ^ VALUATIOY`l'r .sem O O a ✓ TEMP METER OR POLE INST. POWER DEVICES SWIMMING POOL ELECTRIC Up UTLEISSWITCHES IXTURES NEW RESIDENTIAL ELECTR �'�' five dollars ($SM. owner of the property, or my employees with wages a their sole STOW ES TYIsE CONSTRVCTION' pensation, wi ldothe work andthemmeem, Is net intended or offered for a (Sec. 7064 Business and Professions Code: The Contractors License Law does not apply to an ower of property who builds or Improves thereon, and, who does such work himself or through his own employees, provided that such OCC. GROUP HIS. UNITS Improvements are not Intended or offered for sale. If, however, the building or Improvement bsold wlthNoneyraro(compigloM1theewnerbu0derwN have the urden of provingthat he did not build or Improve for purpose ofsale.). 7 I, as owner of the property, am exclusively contracting with licensed Contractors to construct the project (See. 7044, Business and Predications Code: Tp QTy„ PLUMBING PERMIT FEE'. PERMIT ISSUANCE FLOODZONE APN The Contractors License Law don not apply to an owner a property who ojes with a Wilds or Improves thereon, and who contracts fee such ple gp(factor(s) licensed pursuant to the Contractor's License Law. c LI ecI am exempt under Sec. B k P C for this ron ALTER -DRAIN k VENT- WATER (EA) BACK FLOW PROT[CT. DEVICE FEE SUMMARY QImqIDEFEES DRAINS FLOOR ROOF, AREA, COND. FIXTURES PER TRAP SANITARY Y_ N_ RECEIPT N OwnerDate K WORKMAN COMPENSATION DECLARATION ❑I hereby aifkm that 1 have a certiRcete of consent to SCHOOL TAX Y N self -Insure, or a certificate o(Workers'Compensation lvuranm oracerti(ied ro 3800, Label,CO copy thereof (Sec. RECEIPT GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N Policy N RECEIPT N GAS EA. SYSTEM -OVER 4 (EA) Core Com any BUILDING DIVISION IT:ES copy is filed ❑ Certified ropy b filed with [M city Inspection division. the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE GREASETRAP CERTIFICATE OF UEMPTION MOM WORKERS' COMPENSATION INSURANCE IThie section need not be completed If the permit b toren¢ hundreddollars ($100)or less) I really that ts the performance of the work for which this permit is issued, I shalt not employ any person In any mmrner so as to become abject to the Workers'Comim000l, Lawsof California. Date PAIn Date RCCCI tg SEWER -SANITARY -STORM EA. 200FT, WATER HEATER W/VENT/ELECTR ENERGY FEE Y N — PAID WATER SYSTEM/TREATING Applicant NOTICETO APPLICANT: If, after reading this Certificate pr is Exemption, you Code,shoulyou becons, sforth forto thwith Code, you mull 70rthwlth comply with such provisions or this permit be co Workers' Compevasonprovhiovrmit of slab e, deemed revoked. Date Recei tN NEW RESIDENTIAL PENCE. SQ.FT. �� TOTAL: /s BUILn 'E CONSTRUCTION LENDING AGENCY I hereby affirm that there b a construction lending agency for the perform arcs of the work for which thb permit b loved (Sec. 3097, Civ. C.) TATA: _ SEISMIC FEE ELECTRIC FEE ot Landers Name Lenders Addrea IceAifythatlhavereadthbapplkatbnand&atethattheabovelnformrtlon Is coma.I agree to comply with all city and county ordinances and gate laws relating to building construction, and hereby authorize repmentatives of thio j QTY,. -MECHANICAL PERMIT FEE ., PLUMBING FEEr+ MECHANICAL FEE PERMIT ISSUANCE FEES PAID: city to enter upon the above-mentioned property for inspection purpeaes. (We) agree to ave, Indemnify an d keep harmless the City of Cupertino ALTERORADDTOMECH. Date ReCel tN against naelitles,judgments, cogs and expenses wh ch may In anyway accrue a a amsequen th a his permit jhj 2 AIR HANDLING UNIT (TO 10,000 CFM) SUBTOTAL: AIR HANDLING MIT (OVER 10,000 CEM) CONSTRUCTION TAX EXFIAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: Stratum of App nt/Contracor def7 Date HAZARDOUS MATERMLSDISCLOSURE HEATING UNIT (TO 100,000 BTT!) - Will the applicant orfoome building occupant store or handle hazardous material a de0ned by the Cupertino Municipal Code, Chapter 9.12, and the Date Recei HEATING UNIT (OVER 100,000 Will TOT �— Elvlthand Safety Code Section 25532(a)7 — Yes No VEMILATION FAN (SINGLE RESID) ISSUANCE DATE ill the a ppllmnt or tum building occupant use equipment or devices which emit hazardous air contameramo cue aeRruM by the Bay Area Air BOILER -COMP PEE' OR 100,000 BTU) Qua lily Management D❑istdct7 qYea N No haverria lealthhe a tet Code, Se requirements6.95 of the ons 2555,2553 and 25534. Coda Sections Sly have a amass, than] erstan thatIfthh building understand that l(the builaing dos not currently haveatenanL that ltbmy 1� M n AID BOILER -COMP (OVER 1110,000 BTU) NEW RESIDENTIAL MECH. —SQ responsibility responsibility to notify the occupant of the requirements which moat be met prior to issuance efa Certificate of Occupancy. MAR 23 1 `.T W. s Owner or authorieed agent Date TOTAL: OFFICE COPY