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23075 (2) . APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY. Building Pro'ed identification PERMIT NO. 'Building Ad _ 23075^07C ser - one: A AL DAIE s - .2 4 Ola$- CITY OF CUPERTINO-BUILDING DIVISION 1 � Contract ea: fL�{� LI.No: APPLICATION L PERMIT 1 ' '`"�� _ BUILDINGELECTRICAIPLUMBING-MECHANICAL CATEGORY. CONTROLN Architect/Engine r. Llc.No: 94– QTY, ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address PERMITISSOANCE 1:1 1:1 ❑s �y ' LICENSED CONTRACTOR'S DECLARATION �_t} Ihereby affirm, on700that livlWoA3oftheunder pessand Pot Cssuens9(mmmrnc APPLIANCESRES[DENTIAL' JOB DESCRIPTION Ingwith S.full 000)of Dlaffect o(the Businneand Pro(esNonsCode,and my - J Ii mns ie In x d effect. PANELS License Class Date CordvctorUP TO 2DDAhTS ' ARCHITECTS DECLARATION 201-IODDAMPS _ po±p CZOq I understand my plana shall be used as public words. OVER I ODD AMPS - SO.FT.FLOOR AREA SM.FT. Fd Licensed Professiorul SIGNSELECTRICAL ., G�6 Fkro3 OWNER-BUILDER DECLARATION S['ECIAL CIliC[71T/MLSC zy, 1herebyafBrmflem I am exempt from the Contractor's License Law Loathe Ogo following reason.(Section 703].5,Business and Professions Code:An d or f y city TEMP.METER OR POLE INST. cauntywhichrequiresapermltwcomu c"ter,Impmve,dc"Hsh,orrepalr q an ystm=mpdortoiUs ame,alaurequirestheapp0antforsuchpermitto P ryE file a signed statement that he Islicensed pursuant to the provisions of the POWER DEVICES , Q6 3 O t� Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC. .11 elon3af the Buelneeaand Profesloru Code)orthat hebessmpttherefrom and VALUATION Qthe basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHES-FIXTURES applicant fora permit subjects the applicant to a civil penalty of sot more than five 1,is demodollarthepro NEW RESIDENTIAL ELECTR SQPT. STORIES TYPE CONSTRUCTION �n ❑I,a owner of the property,or my,employees with wages r their sok , mm(Sec.7 7044,Business work and the s Code: Isnot intended oroffered for doe(Sec.apply to Wa ow and f property rope ty Code:The or impdole License Law dos notapply torn ownecolprough hiswho nemporimprovntbereoryand that such OCC.GROUP RES UMTS whoovesweloments are norhimself edorough his own le.If,yees,owe providpraise building or tmprovements sdd itis Intendedorsle.ILh ner-g flder illhave TOTAL: Improvementtseold withinoneysarofcompldbRtheowner-budderwlllhave tltur en of provlogthat he dldnct build or Improve for purpose ofskJ, QTY, PLUMBING PERMIT FEE FLOOD ZONE APN LJ Las owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE contractors to mostmet the project(Sec.7044,Businessand Professions Code: The Contractor's License Law don not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) builds or Improves thereon,and who contracts for sock pwjmu with a FEE SUMMARY ,Ilt doral licensed Forecast to the Contredoes License Law. BACK FLOW PROTECT.DEVICE 1_J(am exempt under Sec B&P C for this recon OUTSIDE FES Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N RECEIPT N WORmthat COMPENSATION DECLARATION HX'NRES PER TRAP SCHOOL TAXI Y_ N_ ❑I hereby affirm that i have o Insurance of consent to copy thereof ora RECEIPT N cedi(late ofWorkers'Compesatlan lrinuranaoaa certi(kd copythereof(Sec. GAS EA.SYSCEM-1 INCA OUTLETS PARK FEE Y_ N_ 38W,yLpb CJ a�O�.L RECEIPT# GAS EA.SYSTEM-OVER 4(EA) Com any - - BUILDING DIVISION FEES [�CertlBed copy Is ereby tum she GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE Cedlled copy ts(Ikd with the tlty Irupectbn division. CERTIHCATEOFEXEMPTION FROM WORKERS' GREASETRAP PAID INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recei t# (Thissedion need COMPENSATION copletedpermit Is(orone hundred dollars ($100)orles.) WATER HEATERW/VENT/ELILTR ENERGY FEE Y N I mrtifythat in the performance of the work for which this permit Is blued. I shall not employ any person in any manner an u to become subject to the WATER SYSTEM/TREATING Workere'Compensadon Lawsof Califomla.Data PAID O Z Applicant NEWRPADENTIAL'PLMB, SQFT. Date Rece1 [# 'Z O NOTICE TO APPLICANT:E,aNer ma king this Certificate of Exemption,you should become subject to the Workers'Compensation provisions ofthe Labor TOTAL: W Code,you most forthwith comply with such provisions outlets permit shall be Wj deemed revoked. i. BUILDING FEE d C CONSTRUCTION LENDING AGENCY 'SEISMIC FEE I hereby afflrmthat there Is a construction lending agency for the perform ELECTRIC FEE 0 ante of the work for which this permit is Issued(Sec.3097,Civ.C.) TOTAL; Lenders Name - PLUMBING FEE LL H Lender'sAddress QTY. MECHANICAL PERMIT FEE MECHANICAL FEE 0W IcedifythatIh vereadthkappUmtionandrtatethatthea'save lnformatlon ucorrect.[ complywlthalldtyand county ordlnanceeandatale laws PERMIT ISSUANCE �^ FEES PAID: } 1 relathe With. conatrodion,andherebyauthorizerepresentatives..this .F.. N cityt enteru the above-men ed property for inspection purposes. ALTER OR ADD TO MECH. ? e)a fire a save,Ind d keep harmless the City of Cupertino Dale Recei t# V agains b les,' nd expenses which may in anywayaocrue AIR HANDLING UNIT(TO 10,OWCFM) SUBTOTAL: against icy f egrantingofthlspennt AIR HANDLING UNIT(OVER 10,OWCEM) CONSTRUCTION TAX Signature of AppBant/Contractor Data E)(HAUSTHOOD(W/DICT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant orfuture building occupant store or handle hazardous HEATING UNIT(TO 100,ODO B'CU)�� /� Date Recei material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and SafetyCade Section 7.5532G)7 HEATING UNIT(OVER 100,"BTU) TOTAL• �— ❑Yea M No Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) ISSUANCE(DATE which emit hazardous air contaminants as defined by the Bay Area Air pia 14allty Management District? BOMER-COMP OHPOR ID0,000 BTU) 1 p— A L��Yea ❑I�No have read the hazar7i our materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,DDO BTU) the California atifth&9fety Cade,Sections25505,25533have teent that ] C responsibility that notifybuilding doesthe occupant not a currently haves which most b met NEW RESIDENTIAL METH.' SQ.FT Ec"6 1991 responsibility to realty theompant.(Hiss requirements which must be met a.., 'f ' prior to issuance ofaCedlBate o(Ompanry. IL/ (�J• VEc 1 Owner or authwlred agent Date TOiW ISSUED BY. CS v OFFICE COPY