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24307 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PEBMIT NO Building Add'sO 3 b i e' M A N- _ - 24307 neru^ •' a Q. e. CITY OF CUPERTINO-BUILDING DIVISION ©-7 1y^ c°n °K' ' �� r1C APPLICATION / PERMIT �^�`�L— • " I l BUILDINGdECTRICALPLUMBMG-MECHAMCAL CATEGORY CONTROL N Anehimet/Engincer. Lk.No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: PFRh4TISSUANCE... PLUMB M�11❑ LICENSED CONTRACTOR'S DECLARATION Thereby dBrm that l am licensed under provbloes of Chapter 9(comerenc APPLIANCESRESIDE JOB DESCRII'UON mgwlthSedmn7(XD)of Divigm3ofthe Busmeaandr'rofndoaCodaand my Iiconee la In mI and dlett. ` PANELS , 1� Llnna a_ _LIc.N S¢1s'z i� List rador L4 ARCHITECTS DECLARATION 2W@10ffAMPS q�++O ZO I understand my plans shall be used as public records ION)ANYS A SQ.FT.FLOOR AREA $/SQ.FT. E Z Licensed Professional SIGNS EL C �<< OWNER-BUILDER DECLARATION 9'ECL3L UIT/MLSC z l.., IherebyafOrmthatlamexemptfromthe Contmdor's Llmnwlaw/orthe following reason.Cedion 70315,Buslnee and Prof.®ions Code:Any dtyor FEl muntywhich requires a permit tomrotrud,alter,Improve,demoish,ormpalr TEMP.METER ,NST. - nia anyawdurc pdorm Its bsuarKe,abo requlretheappBant for such peeNt to - D �S Ob a signed statement that he is Bernard pursuant to the provblom of the 3 u. Contndorb Llcenm Law(Chapter 9(coenumiog with Section 7000).f Dm- hING POOL ELECTRIC slon3 ofthe Buslnesesnd Professbru Code)orthat he beumptthemfromand VALUATION < the basis!or the alleged exemption. Any violation of Section 70715 by anyanI171E.�5WLfCITFSHJ(7llfiis LOI Qto�l appBtlorapemdtsubjedstheapp0enttoadvilperaltyofndmarethan L CJFJ live hundred dollars(5500). �n ❑I,as owner of the property, NEW RESIDENTIAL ELECTRSQ.Fr. STORIES TYPECONSTRUCTION p perry,or my employees with wage as their sole C col.(So. 0K Iiilldo the work,rufmah estmde:The C Intended or offeredLaw '$ dile(Sea 7076,to alnessandf propcty Code:The Cimproves Meanie Law S$ don rot apply torn owner ofproperty who nemporimprwatheme,that such OCC.GROUP RES UNITS who doessuch work hlmmBodorwgh his owne.If,ho eprovidedthatsuch improvements are not Intended ore(lered(mule.If,however,thebuilding or ' Improvementbsold wbhinoncyearolcompldbn,theowner-bu0derwRl have fit]Zurden of proving that he did not Wild or improve for purpose of sale.).mQTY. PLUMBING PERMIT FEE FLOOD ZONE APN U L as owner of the property,am exclusively ntndlng with licensed PERMIT ISSUANCE ��.s contncmrs to construct the project(Sec 7074,Business and Professions Code: The Contractor's License Lew does nor apply to an owner of property who ALTER-DRAIN k VENT•WATER(EA) be0ds or Improve thereon,and who contracts for such File s with a FEE SUMMARY cgBle fador(s)Lnsed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE LJ I am exempt under Sea I B k P C for this mason pUTsI OF.FEES DRAINS FLOOR ROOF,AREA,COND. NITARY Y_ N Owner Drte i RECEIrTN WORKMAN COMPENSATION DECLARATION pl%IIJRESP iODL 7A% Y N ❑I hereby affirm that I have a conlBcate of consent to self-Insure,or a RECEIPT mnlBmteofWorkeni Compensatlonlmuranmorandifk mpythercof(Sec. GAS G. -i RK FFP Y N 3800,Lab C3 e q A► 9O RECERN PdkyY Com nv yrFJ — GAS G.SY -0 6 ) BUILDING DI VISION FEES �Cedlled cup v relay furnished. CRGSE/1NDUSE PLA HECKFEE � 11111Z copy b filed with the dty InspMion divldon. CERTIFICATE OF EXEM PT ION FROM WORKERS' CREASE"MAIR PAID . COMPENSATION INSURANCESEWER-SANITARY-SfORMG MOF[. Date Reeel tin (TMssedlon need not be completed lithe perent b!Drone hundred dollars ($100)or lea.) WATER HEATER W/VENT/EI.ECTR ENERGYFEE Y N I sad Irss.)l m the performanceofthework lorwhlch this per is hued, I shall not employ any person In any manner w as to become subject to the WATER SYSTEM/TREATING Worker Compensation Lases of California. Date PAID Z NOTICE Applicant NEVA RESIDENTIAL PLMR. SQ.FI.. Date Remi tin NOTICE TO APPLICANT.If,akar making this Certificate of Exemption,you Hshould bNm..ubkct to the WorkerComperuat ion provisions of the Labor TOTAL: L CC Code,you=at forthwith comply with such provisions orthb Nreeft shall be �ass" LU > deemed revoked. BUILDING FEE a c CONSTRUCTION LENDING AGENCY SEISMIC FEE lherebyafBrm that there ba mnstrudlon lending agency for the pedorm T ELECTRIC FEE 4 7 Z anmoftheworkforwhlchthbpermt6t ed(Bec.3097,Civ.C.) U O lenders Name PLUMBING FEE LL I- Loodere Address QTY. MECHANICAL PERMIT FEF MECHANICAL FEE O W Inrtilythatl have mad thbapplleathmand A.mthattheabovelnf.maHon fl. brr coeat.I agreeto comply with all city ty and county ordinances and state laPERMIT ISSUANCE FEES PAID: >. n,W relating to building construction,and hercbyauthonrerepersentativesofthis - H cltytoenteruponthe above�menfimed property for inspection purposes. ALTER OR ADD TO MECH. Z Z (We)agr to ave,Indemnify an d keep harmless the City of Cupertino Date ReceiP[# ag.hatil.bil ,jadg b,mstsand expenses which may In anywayaceme AIR HANDLING UNIT(TO I(LODO CFM) SUBTOTAL: ag.mual try n enoeofthe gofthlspemit. �� L t/ AIR HANDLING UNIT(OVER 10,000 CIM) CONSTRUCTION TAX Sig B tra r ate EXHAUST STOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARD MATERIALS DISCLOSURE Will the applicant orm building occupant store or handle hacardous HEATING UhTT(ID 100,000 BTU) Date Rmei til material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the Health and SafetyCade Section 25532(a)2 HEATING UNIT(OVER IOO D00 BTU) TOT ❑Yn rj No WWlhe applicant or mm building occupant use equipment ordevic.s VENTILATION FAN(SINGLE RESID) ISSUANCE DATE which emit harardous aU mora Mnanle as defined by the Bay Area Air Quality Management Dlstnd2 BOILER-COMP OHP OR 700,000 BTU) ` Yrs No II have read the hazer our materials requirements under Chapter G95 of BOILER-COMP(OVER100,000 BTU) B the California Health k Snfely Code,Sedioa 25505,25533 and 25537.1 understand that if the building don nM currently have a tenant,that it is my NEW RESIDENTIAL MEC . M SQ.Fr rnpoalblllty m nfaCereacte of Occupancy. mqulremenb which nwst be met OCT 49 qQ� price to Lofty to notify the Certificate of ofthomq Owner or authorlud agent Data ISStrgt2BYor 11' s TOTAL: OFFICE COPY .