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23954APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY Building Project Identification - BuOtling Address: ' ��� •�Y/tV.�R PERMIT NO. _ 23954 an,e one. A - CITY OF CUPERTINQB G DIVIS APPLICA 1 PER Cd 'e Name; Lic.N CATEGORY _ CONTROL# _ BUILDNG C PLUMBING- GL Architect/Engineer. io n QTY FUR RI P FEE BUILDING PERMIT INFO Address: C C PERMIT UANCE �^ ❑ LICENSED CONTRACTOR'S DECLARATION I hereby affirm that l amllcensed under prwislonsaf Chapter 9(commen Section Seon 7000)of Dlvision3 ofthe Business and PmfeaclansCode,and my license is In full form and effect. APPLIANCESRESIDE JOB DESCIUFFION 'PANELS L nseclass Lk.I Da a Contractor 701-IODO AMPS - ARCHITECT'S DECLARATION iunderstandmyplamshallbeusedaspublicrerorde. OVERIOOOAMPS SQ. FT. FLOOR AREA $/SQ. FT. Licensed Professional SIGNS ELECTRICAL SPFCIALCBiC[AT/MLSC OWNER -BUILDER DECLARATION I herebyaffirmthat I am exempt fmm the Contractor. License Law for the TIME. METER OR POLE INST. following reaaon.(Section 7091.5, Business and Professions Code: Any city or countywh ch requires a permlttocorutruct, alter, improve, demolbsh,orrepair anystm=mpriontoiULuuame,alsomquimtheappRuntforsuchpert tto file a signed statement that he is licensed pursuant to the provlalotu of the POWER DEVICES SWIMMING POOL ELECTRIC - UTLETSSWITCHES-FIXTURES Contractor. License Law (Chapter 9(romrrcncing with Section 7000) of Divi- skm3 of the Business and Profesabtu Code) mthat he is exempt therefromand the basis for the alleged exemption. Any violation of Section 70315 by any applicant fora permit subjects the applicant to a civil penalty ofnot more than VALUATION . \ v O a NEW RESIDENTIAL ELECTR SQ.FT. five hundred dollars($500). M I, as owner of the prool property, or my employees with wages as their se STORIES. TYPE CONSTRUCTION rompensallon, will do the work and the structure is not Intended or offered for A' i - sale (Sec. 7054, Business and Professions Code: The Contractors LlceLaw IN does not apply to an owner of property who builds or improves thereo, and Who doessuchwmk himself orthrough hlsown employees, provided that such Improvements are not intended proffered forsale. IL however,thebulldingw _ improvement lssold within oneyearofcompletion, the owner-buiderwlll have the burden of proving that he did not build or improve for purpose of sale.). Lj L as owner of the pmperty, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: QTy, PLUMBING PERMIT FEE .��Flppp PERMIT ISSUANCE Ile Contractor's License Law does not apply to an owner of property who or Improves thereon, and who contracts for such pSojects with a �aI cools) licensed pursuant to the Contractors License Law. am exempt under Sec E recon— k P C for this on ALTER -DRAIN #VENT- WATER (EM FEE SUMMARY BACK FLOW PROTECT. DEVICE OUTSIDE FEES DRAINS FLOOR A, ROOF, AREGOND. SANITARY Y N RECEIPT It Owner Date WORKMAN COMPENSATION DECLARATION [:]I hereby affirm that I have a cemficate of consent to self -Insure, w a certlRcate a(Workere'Compematlonlmurance ora certRled copythereof (sec. 3800, Lab C.) - Policy # FLXTURF_S PER TRAP ` SCHOOL TAX Y N RECEIPT# GAS EA. 9YSTEM-1 INC.4 OUTLETS - PARK FEE Y_ N RECEIPT # GAS F.A. SYSTEM-OVER4(EA) Y BUILDING DIVISI NFEES erlifird copy la he d With t le city CertNed copy is with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE 1 GREASE TRAP CERTIFICATE OF EXEMPTION FROM WORKERS' ' COMPENSATION INSURANCE (This section need not be completed if the permit la forms hundred dollars 7 1 PAID Date Recei tom• SEWER -SANITARY -STORM EA. IDOFT. _ WATER HEATER W/VENT/ELECTA ENERGY FEE Y N_ ($10(dorless') I rerti/ythat in the peAormance of the work forwhich this permit Is issued, WATER SYSTEM/TREATING I shall not employ any person In any manner ro as to become subject to the Workers'Compensation Laws of California. Date PAID AppN0110Et NOlicant MPLIGNT:IL after makingthb Certlfitate of Exemption, you should become subject In the Workeri Compensation Prov"%. of the Labor NEW RESIDENTIAL PLMB. SQFT. Date Recel t# - TOTAL: BUILDING Code, you =at forthwith comply with such provisions orthis permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE t Iherebyafnrmthat there la a construction lending agency for the perform- ance of the work for which this permit is busied (Sec. 3097, Civ. C.) Lender's Name Lenders Address lurtlfythatlMvereadthlsapplbutbnand&atethattheaboveinformatim Is correct.I agree to comply with all city and county ordinances and gate laws TOTAL: ELECTRIC FE PLUMBING FEJE QTY. MECHANICAL PERMIT FEE MECHANI FEE �� PERMIT L95UANCE'' FEES PAID: relating tobullding construction, and hereby authorize representatives of this city to enter upon the above-mentioned property for Impaction purposes. (We) agree to axi Indemnify an d keep harmless the City of Cupertino against liabilities, lodgments, cose.nd expense which ma Jn.ny wayacaue Date Receipt# t ALTERORADDTOMECH. AIR HANDLING UNR(T010,000 CFM) - SUBTOTAL: against Id Ci in ronsyu ceof gra permit. AIR HANDLING unnr (OVER ]D,aoocFM) CONSTRU NTAX no' u er w Date - A RDOUSMATERIALS DISCLOSURE Wlllthea he future building occo ant store or handle hazardous PP R P material as defined by the Cupertino Munldpal Cade, Chapter 9.11, and the Health and Safety Code Section 25537(a)7 F1 Yea No EXHAUSTHOOD(W/DUCT) CONSTRUCTI N TAX PAID: Date Recei t# " HEATING UMT(TO 100,000 BTU) HEATING UNIT (OVER 100,000 BTT]) T' i VENTILATION PAN (SINGLE RESID) ISSUANCE DATE Will the applicant orfuture building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air' Quality Management Distinct? 4Youn❑ No havcreadthehazar7ouamatedalsrequimmnmunderChapter6.95of the Califumla Health & Safety Cod, Sections 25505,75533 and 25534. I understand that if the building does not currently have a tenant, that it is my p� p r A I D. JUL 20 1(1 X77 BOILER-COMP©HPOR100,000BTU) BOILER.COMP(OVER 100,000BTU) -' NEW RESIDENTIAL MEIN. 5QPT responsibility to notify the occupant of the requirements which resat be met /a prior to issuance of a Certificate of Occupa ncy. V 1 1 I55UEDBY Owner or authorized agent Date OFFICE COPY