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23525 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PFat.MIT NO. Building Addrea: Z - 23525 nen(—�1ame: one: R CITY OF CUPERTINO-BUILDING DIVISION Conlractor'BNan'e: ,1 ua.Na: APPLICATION / PERMIT V� l C�1>.T��IS C''l�Uh� I BUILDING-ELECTMCAUPLIIMBINGMFDHAMCAL CATECORY CONTROLY (tett/Engineer. Lic.N. QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO Address: PFRh4TISSUANCE ❑ ❑ ❑ sr LICENSED CONTRACTOR'S DECLARATION Pd I hereby affrmthat l am licensed under provisions of Chapter9(mmmenc APPLIANCESRESIDEN[TAL JOB DESCRIPTION Ingwlth Sedion7001Bo(Dlvlsion3oflhe Busi a and ProfeaslonsCode,andmy license is In foil force and effect. PANELS - LlanseClan _ Lic# 4021(31 Date_y Contractor p��) ARCHITECT'S DGCLARATIO2 N 701-10DOAM1'S Oz I understand my plaru shall be used as public records OVER 1000 AMPS - SQ,Fr.FLOOR AFtA $/SQ.FT. O Iy Licensed Professional SIGNS ELECTRICAL - OWNER-BUILDER DECLARATION `I A L E D In SPECLILCIRCUIT/MISC I Ta 7E, Iherebyafilrmlhatlam exempt from the Contractor's License law forthe following iSectionrmitto Business and Proprove, Coda:Mycity it M P U T E 0�� fountyng ich Mason.(Section 7Mtto construct and Prolpsions CociteAor repair TEMP.METER OR POLE INST. anystructure prions Its luuance,also requlastheapplicant for such permit to ryC f le a Mgned statamem that he islicensed pursuant to the provislom of the POWER DEVICES 3 O Contractor's License Law(Chapter 9(commencing with Scotian 7000).f Diol- SWIMMING TOOL ELECTRIC T Mona of the Business and ProfewimuCade)orthat heh exempt therefromand 6 5 the bash for the allegedexemption. Any violation of Section 711313 by any OUTLETSSWITCHESFIXTURES OA applicant fare permit sub)ecMthe applicant to a civil penalty of no more than R five hundred dollars(SM. NEWRESIDFNIIALELECIR M I,as owner of the property,or my employees with wages as their sole SQ.FT. STORIES rME CONSTRUCTION 7� compensation,will do the work and the structure is net Intended or offered for sale(Se.7074,Business and Professions Code:The Contractors Llama Law does not apply to an owner of property who build&or Improve.thereon,and OCC.CROIII' RpS.UNITS who doessuch work himself orthrough Mw son employers,provided that such Improvements are net intended...Bernd tarsale.If,however,thebullding or TOTAL: improvementissoldwithln oneyearofcomple ion,theowner-bulkierwlll have 0A.Ilrrden of pnrving that he did out build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD7DNE APN U L as owner of the property,am exclusively contracting with licensed PERMIT NUANCE .=am to mlulNct the project(Sec.7044,Business and Professions Code: The Contractors License Law dm not apply to an owner of property who builds or Improve thereon,and who contacts for such pwjmu with a AL1FR-DRAIN k VENT-WATER(EA) mpp�Iflador(O licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY Inal am exempt under Sec B k P C for this mason DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N— • Owner Date RECEIPT Y WORKMAN COMPENSATION DECLARATION FIXTURESPERTRAP SCHOOL TAX Y N ❑uftifl hereby affirm that 1 have o cert)m of consent m opy the s ora RECEPT'Y WW'LabofWorkers'Compenutlonlruuranceaacertl(kd copythemof(Sec. GAS EA.SYSIM.1 INCA OUTLETS PARKF� Y N Polis Lab CJ Policy q GAS F.A.SYSTEM-OVER 4(EA) RECEIPT p Com any BUILDING DIVISION FOES �Ce"Bled copy h herebyfurnished.the city CREASE/INDUSfRL WASTE INTERCEPTOR PLANCHECKFEE Certllied copy h filed with the city Inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWER-SAMTARV-STORM EA.700FT. - Date Recei [# (This section need na be compldM If the pemdt h foram hundred dollen (S100).tifythat WATER HEATER W/VENT/ELECTR ENERGY FEE Y N ]certify mplo l.ry pehe r many ner sorwhich thisl learnrmit I.w t . — I shall not employ eny per.on in any manner ao a to be me wbject to the WATER SYSTrM/TREATING Worlicant m it.n awe of cYl�t la.Date L PAID O Z nppucantp ) T pUL1>, CO�j5 Z (3 NOTICE TO MPLICANT:IL after making this Certificate of emptlon,you NEW RESIDENTIAL PCMB. SQ.FT. Date Recel f# Hshould become sobject to the Workers'CompensM ion provhloru of the Labor TOTAL: NCCCode,you=at forthwith comply with such provhloru or this permit shall be j deemed revoked. BUILDING LUG CONSTRUCTION LENDING AGENCY reSEISMIC FEE I heby aftirmthat there Is a mmtrvctlon lending agency for the perform ELECTRIC FEE M Z znee of the work for which this permit h issued(Sec.3097,Civ.C.) TOTAL: U O Le dar'e Name PLUMBING FEE LL Y- Iandce.Addrea, - QTv. MECHANICAL PERMIT FEE MECHANICAL FEE OW Iartifythatl have read this applicallonand statethal theabovelnformation 1 ism.rect.I agretwannply with all city and county ordinances and Mate laws PERMIT ISSUANCE FEES PAID: } relating to building mmtrualoo,and hereby authorize representatives ofthis Z city to enter upon the abovcmentioned property for Inspection purpose, ALTER OR ADD TO MECH. Dti[C Recei f# — (We)agree to save,Indemnify an d keep harm(.the City of Cupertino P against llabilitks,IidgmenI cont dexpenxre which.ylo..yw.yamu. AIR HANDLING UNIT DO 10,ODO CFM) � SUBTOTAL: against said ity In con rue oft granting of this permit. ln. AIRHANDLING UNIT(OVER Io,000CFM) CONSTRUCTION TAX Sigmn of Applicant/Contractor Date EXHAUS"T HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant Mone or handle hazardous HEATING UNIT(T0100,000 BTU) -Date material as defined by the Cupertino Municipal Code,Chapter 9.1$and the _ ReceI [# Health and Safety Code Section75537(a)7 HEATING UNIT(OVER 100,DM BTU) TO A ❑Yrs No Will the applicant or No building occupant use equipment or devices VENTILATION (SINGLE RESID) ISSUANCE DATE whicheMhazardousaircats as defined by the Ray Area Air Quality Management District? BOILER-COMP pFN OR]W,IXq BTU)4 No P Yce p# haver California Health Safety materials Sections 25505, 55aChapter.1 of BOILER-COMP(OV112100,g10BN) N the tandt Health ithe building Code, otcur&75505,ve a t and 25534.I �� understand that notify the exc dans notheaqulyhavea tenant,that it is my NEW RESIDENTIALMECFL SQ.FT 1 .5 1992 responsibility to nai(y the oavpant of the mquirertenU which must be.rat prior to Issuance of a Certificate of Ora pa my. CIlY IJ Owner or authorized agent Date r— ISSUED BY; OFFICE COPY