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23656 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY B.ildimi Project Identiflcatlun PERMIT NO. Building Address: 6(S'O s-li"e J .. CITY OF CUPERTINO-BUILDING DIVISION nets ame� one: 5 con adMdN : Llc•Nn: APPLICATION / PERMIT NC Iuoo 1 BUILDINC-ELECTRICAI.PLUMBING-MWHAMCAL CATEGORY CONTROL M Architect/Engineer. ` ('}•19/Nyt BUILDING PERMIT INFO QTY ELECTRIC PERMIT FEE Address PERMITISSUANCE El ❑ LICENSED CONTRACTOR'S DECLARATION - I hereby aRirmthat l am Licensed under provisions of Chapter 9(commsc- APPLIANCESRESIDENHAL JOB DFSC ON Ingwlth Sec on7000)o(Dlvlsim3ofthe BuslnesandPmfesionsCode,cad my rce - license Is In full foand citedPANELS . License Clam C z L Lic. _ Date Contractor ARCHITECPS DECLARATION 201-1000 AMPS M0 I understand my plane shall be used as public records. OVER1000AMPS SQ.FL FLOOR AREA S/FQ.FT O C Llansed Professional SIGNS ELECTRICAL Q w OWNER-BUILDER DECLARATION to SPECIAL CRiCU17/MLSC �.., rm Iherebyaflithat lem exempt from the Contractor.Licence Law for the - - 2—❑ following reason.(Section 7EI Business and Professions Code:Any city or TEMP.METEROR POLE INST. K� caunis tywhlch requlmsa permittocosm truct,alter,improve,deolish,ormpalr s q 3 anyetmcture priortoitsiawance,also requlrealhe applluntforeuch permit to POWER DEVICES 6 r Rle a signed statement that he Is licensed pursuant to the provisos of the - p� Contred.e.License Law(Cha er9(commendn with Section 7000)of Dlvl- LUATION i. R SWIMMING POOL ELECTRIC the WaifothealleedexemptlosC nyviothrthels exempt therefrom and 5�p�u o the balls for the alleged exemption. Any violation of Section net room by any OUTLETS -FIX[URES. applicant fore permit subjects the applicant to a penalty oo civil pelty r more than gg five hundred dollars($500). SQFT. STO MI, RIES CONSTRUCTION r9,Ic` NEW RESIDENTIAL ELECTR compensation,as owner of the property,or my employes with wags r thele door offered for O sale(Sec.7044,Business and Profeslone Code:The Contractors Llcese law $ does not apply to an owner ofproperty who builds or improve thereon,and whodoe such work hlmselforthrough his own employees,provided that such - OCC.GROUP RFS.UNITS improvements are not intended oroffered for dale.lf,howevegthebuildingor " .TOTAL; I improvement is sold within oneyearofcompletion,the owner-bullderwlll have t men of proving that he did not build or Improve for purpose ofsle.). QTY, PLUMBING PERMIT FEE PLOODZDNE APN �I,as owner of the property,am exclusively contracting with licensed rontractors to construct the project(Sec.7044,Business and Professions Code: PERMIT ISSUANCE � , The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) Wilda or Improve,thereon,and who contrada for such pro)ed,with a FEE SUMMARY CcRtl�dor(e)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE, LII am exempt under Sec. B&P C for this reason OUTSIDEFEES DRAINS FLOOR A,ROOF,ARECONE). SANITARY Y N_ - Owner Date RECEIPT If WORKMAN COMPENSATION DECLAMATION FIXTORE&PER TRAP SCI100L TAX Y_ N_ ❑I hereby affirm that I have a certificate of convent to self-Insure,ora RECEIPT k certificate of W/o��n P'eru)sjy�Insurance oracertiBed mpythereof(Sec. ' CAS F.A.SYS[EM-1 INC.4OUTLETS PARK FEE Y_ N 3800,lab CJ/ r/� /�/ RECEIPTY Po11ryY r GAS F.A.SYSTEM-OVER4(EAI, Com ann� r BUILDING DIVISION FEES - �Certlil copy is herebyth the city i GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE �Certified spy ls(lied with the city inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID ' COMPENSATION INSURANCE SEWER-R-SANITARY-STORM EA.200FT. Date• Remi t# (Thisseetion need not be completed lithe permit isforone hundred dollars ($100)oIcerti(ythaify that WATER HEATERW/VENT/ELECTR ENERGY FEE Y N t in the performance of the for which this permit is Issued, I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING - Workers'Compensation laws of California. Date PAID z Z Appliwm - NEW RESIDENTIAL PLMB. SQ.FE Date Remi t# Z O NOTICE TO AI'PLICAM:$after making this Certificate of Exemption,you should become subject to the Workers'Compesatlon provisions of the Labor TOTAL: N Code,you must forthwith comply with such provisions or this permit shall be W > deemed revoked. - CONSTRUCTION LENDING AGENCY SEISMIC FEE d C I hereby affirmthat there is a comemactlon Lending agency forthe perform- O ELECTRIC FEE Z ante ofthe work for which this permit is Issued(Sec.3097,Civ.C.) O O Lender.Name - PLUMBING FEE LL F Lender's Adelman QTY. MECHANICAL PERMIT FEE MECHANICAL FEE - OW I certifythat I have readthls application and statethatthe above Information 4 Iscorred.I agresto comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID: �. N relating to building construction,and hereby authorize representatives of this 11 to entero the above-mentioned ro for Inspection a ALTERORADDTO MECH. 1' 2 `y F pe113' F� p"rpOBe' 'Date Recei t# V — (We) indemnify and keep harmless the City of Cupertino - P agalmtl I lee,' gmenh,cod[d an expenseswhich may In any wayaccrue AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL: .gals ai C na9naeque a ruing of this permit AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX Signatureo AppBunt/ ont or t1 Date EXHADsT HOOD(W/DUCT) CONSTRUCTION TAX PAID: NAZA US MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Ref:6 t# material as defined by the Cupertino Municipal Code,Chapter 9.12,and the s Health and Safety Cade Section 25532(a)t HEATING UNIT(OVER 100,000 BTU) TOTAL: ❑YesNo Will the applicant or building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) _ ISSJJANJCE DATE which coat hazardous ab contaoanantsas defined by the Bay Area Air La CE DA Quality Management D❑istrict? BOILER-COMP OHP OR 100,"BTU) V 4 Ys d No NA If/ �-. have read the bazar ous materials requirements under Chapter 6.95 of BOILER-COMP(OVER l0llito BTU) MAY 1Ja7 the W Lifemla Health&SafetyCode,Sections 25505,25533 and 25534.I understand that if the building dos not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FF yx rspoexibility to notify the occupant d the requirements which must be met CITY Ur prior la Lmuance of a Certificate of Occupancy. L•t1YCh l f)yy/1/11 Owner or aulhodzed agent Date TOTAL: ISSUED BY-. OFFICE COPY