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23863APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY Building Project Identification B"°ding Addams: i i4, , _ PERMITNO. 23863 cern aonC: ones /LI CHAZ ase an CITY OF CUPERTINO-BUILDINGDIVISION APPLICATION / PERMIT BUILDING-ELECTRCCAT PLUMBINGMFCHAMCAL �J 1' / Z Contractor's Name: / L✓ 1 LIc. Nei, 5. CATEGORY CONTROLN Architect/Englner. LIc, No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: ❑ ❑((� ❑ �J PERMITISSUANCE LICENSED CONTRACTOR'S DECLARATION I hereby th&di.( MOhatlam Bcrn3.fth.under provisions off a..9(commrn Ing wlth5ection7000) of Dlvfect. ofthe Buainevand ProlesslonsCode, and my Ii= le In _o a c.0 Limn C6 LIC.N t�uZ 7' Date Contract. - Il+3 ARCHITECTS DECLARATION O I understand my plamehafi be used as public records Licensed Professional DECLARATIONSPECIALCIRCUIT/M1SC I herebyafOren that l am exempt from the Contractor's License Law for the reason.(Section 70315, Business and Professions Code: Any city or counlywhichrequimaperedtmromtmd,alteplmpmv dem Ush,orrepair anystructure priorto Ire heuance,abo requims(heappllunt f.rsuch permdto file a signed statement that he Is licensed pursuant to the provisions of the Contrador'a License Law (Chapter 9(commencing with Section 7000)of Diel- slon3 of the Businessand ProfemlonsCode) orthat hein exempt thenefromand the basis for the alleged exemption. Any violation of Section 70315 by any applicant fora permit subjects lheappllcant to a civil penalty of not more than five hundred dollars(5.SM. ❑I, as owner of the property, or my employees with wag" as their sole compensation, will do the work and the structure isnot Intended or offered for sale (Sec. 7034, Business and Professions Code: The Contractors License Taw does not apply to an owner of Property who builds or impneves theme, and who does such work himself orthrough his.wn employees, provided that such Improvements are not Intended oroffered fursale. If, however, thebulldleg or Improvementusoldwlthle bneyearofcompletl.n,lheowner-bu0derwlll have tl)L,tiurden of proving that he did net Wild or Improve for purpme of sale.), LJ L ae or of the property, am exclusively contracting with lim acd mntncims to construct the project(Sec. 7044, Business and Profession Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such pt ojieta wRh a �gB(reasonsdons) licensed pursuant to the Contractor'. License Cow. LJ I am exempt under Sec. R k P C for this reasons APPLIANCFSRFSIDENI7AL JOB DESCRIPTION ,� ��� Alt r /' C/il/LT( -r/!F e PANES � RPS 701-1000 AMPS OVER1000AMPS 4SQ.Fr. FLOOR AREA S/SQ.FT. E(.Bowing I R . 7 SIGNS ELECTRICAL -RINLEDOWNER-BUILDER TEMP. METER OR POLE INST. POWER DEVICES SWIMMING POOL ELECTRIC VALUATION �_ r a OUTLET&SWITCHFSFIXTURFS NEW RESIDENTIAL ELECTR _SQ.Fr. SfORIES TYPE CONSTRUCTION TOTAL: Q y, PLUMBING PERMIT FEE PERMIT ISSUANCE p'71 r U V - ALTER -DRAIN & VENT - WATER (FA) OCG CROUP RES UNITS FLOODZONE APN FEE SUMMARY BACK FLOW PROTECT. DEVICE DRAINS FLOOR ROOF, AREA, COND. FDn ARES. PER TRAP SANITARY Y N— RECEIPT aPENSATION Owner Date WORKMAN COMDECLARATION of content to "If -Insure, ora I hereby affiorkem that I have o Insurance ce IIabcxom of Worken'Compematlonlmunnce oracertifled ropy thereof (Sec. 380D, Lb C.I " Polirya /ctr-73 h�v'L Com any �T ._ - SQlOOL TAX Y— N RECEIPT N GAS EA. SYSTEM-11NCAOUILET$ PARK FEE Y— N RGCER'T« CAS EA. SYSTEM -OVER 4(FA) BUILDING DIVISION FEES Allied copy is herebytd. orlRied copy Is filed withh the the city inspection division. CERTIFICATFOF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE ( m lection need not be completed lithe permit V foron hundred dollars (51 I0)0)or1n.J lcertl(y tmo-Yhat in an person I -any marhe ork for tobhich Niseesubjcrmit is to red, I shake not employ any person In any manner n u to become subject to the ApplicWorkers' Compensation law. of California, Date Applicant NOTICE co APPLICbecome subject tote, after making perhis Ction, rovis Exemption,you Cenle,shoulou=aaurthwit the ply wit'Comperuason pmvbiomrmit the s Lab be naked.at forthwith comply with such provlelom.rth0 permit shall be deemed deemed revoked. CONSTRUCTION LENDING AGENCY I hereby afOrenthat then le it construction lending agency for the perfomr ante of the work for which this permit is Issued (Sec. 3097, Civ. CJ Lender'. Name Lenders Address I cenilythatl have read thisapplirnbn and statethat theaboveinformat er iscorred.I agree to complywith all city and county ordinaressand statelaws 'relating to building construction, and hereby authonae representativesof thio city to enter upon the above-mentioned property for inspection purposes. (We) agree to save, Indemnify an d keep hared.. the City of Cu pen Ines against liabilities, pdgments, costs and expenses which may In anyway amu. .against C In ronxxryen ?tre acing of this pemNL GRPASE/NDUSIRL WASTE INTERCEPTOR PLANCHECKFEE PAID Date Recei IN GREASETRAP SEWER -SANITARY -STORM EA 700Fr. WATER HEATER W/VENT/ELEC'IR /� ENERGY FEE Y N — PAID Date Ip WATER SYSTEM/TREATING NEW RESIDENTIAL PLMB. _SQFI. TA TOTAL: BUILDING TOTAL: C A: a SEISMIC FEE ELECTRIC FEE QTY. MECHANICAL PERMIT FEE PLUMBING FEE MECHANICAL FEE PERMIT ISSUANCE ALTER OR ADD TO MECH. AIR HANDLING UNIT CFO lo," CFM) FEES PAID: Dale Recei tk SUBTOTAL: VISO AIRHANDLING UNTT(OVEe I0,000CpM) CONSTRUCTION TAX g tu 5rcof Appll t/ brocim a64e" A7ARDOUS MATERIALS DISCLOSURE Will theappllunt orfuture building occupant store or handle haeardous material as defined by the Cupertino Municipal Code, Chapter 9.17, and the Health and Safety Code Section 75537(a)7 - ❑ Yes r� No Will lheappllcant or fumm building occupant use equipment or devices which emit haeardouaaircontaednnlsas defined by the Bay Arca Nr Quality Management D❑lstrid7 qYes M No have read the haza esus materiab requirements under Chapter 6.95 of the Coliform. Health k Safety Code, Sections 2S50S, 25533 and 75534. 1 understand that lithe building does not arrently have a mr.ct,thatitlsmy responsibility to notify the occupant of the requirements which must he met prior to issuance of a Certificate of Ocm pa ney. IXFIAUSTHOODMVDUCT) CONSTRUCTION TAX PAID: HEATING UNIT (TO 100,000 BT1p _ Date ReceI t# HEATING UNIT(OVER 100,000 BTU) TAL: t VENTILATION PAN (SINGLE READ) S$UANCE DATE ,r��ld ui �Ur r m i llVV y-y�/ ISSUED By \- BOILER -COMP (7EIP OR I00,0(U BTU) BOILER -COMP (OVER 100,000 OTU) NEWRFSIDEIMALMECH. SQ.2 Owner or authorised agent Date TOTAL: OFFICE COPY