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23438 (2) — T APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PER.MITNO. B"°ding Address: 23438 OGq c e I one: A A A La:1�Q-frP1 F, CTrECn CITY OF CUPERTINO-BUILDING DIVISION Cono-a Name: Lie.No: APPLICATION / PERMIT .3 — Z3 S BUILDING-ELECTRICAL-M' BINC-MECHANICAL CATEGORY CONTR L Y ArcMtect glKer' Lk.No: L7 Qn ELECTRIC PERMITBUILDING PERMIT INFO EE Add.: PERMITISSUANCE © © 1:1 ❑ LICENSED CONTRACTOR'S DECLARATION d I hereby affirm that lam lmmsed under provislonsof Chapter9(roy AP NC C JOB DGSCRII'TION ingwllh SeMon7000)of Dlvi.ion3ofthe Buslnessand Prosl lnonsCade,.ed and mmy limns'.in fou f and effect. (�,,, B {r4���Yx—t-}— Lksn� Llcp ��6 • - ',.,-�. &V'(feYY2LE s'� GM�J Date Contractor/-F--k/ L ARCHInCI'S DECLARATION 201-IODOAMI'S NIO understand my pians shall be used as public record.. OVER100t)" SQ.FT.FLOOR AREA E/SQ.FT. O Licensed Professional SIGNS ELECTRtqA (tl0 caw OWNER-BUILDER DECLARATION _l G � SI'GCIALCIRCUIT/MLSC IhembyafRrmthatlamexemptfmmtheContractorsLiceaeLawfarthe - DO 70 Ofollowing reason.(Section 70315,Business and Professions Code:Any city or ' t.u9TEMP.METEROR POLE INST. cmntywhlchmquimsaper ttommtmd,altepimpmvgder lbh,orrepair anystruttum prior to its buuance,abo requirestheappucant forsuch permit to POWER DEVICES yd file a signed statement that he is licensed pursuant to the provisions of the Contractors License law(Chapter 9(commentlngwith Section 7000)ofDivi. SWIMMING POOL ELECTRIC shm 3 ofthe Business and ProteasionaCede)orthat he is exempt therefromand VALUATION the basis for the alleged exemption. Any violation of Section 70]1.5 by any /�6 OUTLETSSWITCHFSHXTURFS (� applicant fora permit subjects the applicant to a rnll penalty anus more than �i five hundred dollars MOB). NEWRESIDENTIALELECTR SQ.FT. STORIES TYPE CONSTRUCTION F11,as owner of the property,or my employees with wages as their sole < pensation,wuldothe work andthestactureisnot Intended or offeredfor 5 O sale(Sec.7044,Business and Professions Code:The Contractors Llcerse Law {;j$$ does not apply to an owner of property who Wilda or improves thereon,and OCC.GROUP RES.UNITS C. whodoessuchwcrkhlmseltorthrough Msown employees,provided that such Improvements are not intended ororfered forsale.If,however,thebuilding or TOTAL: 30- m Improvement bsold within one yearo(completion,the owner-budderw111 have t rden of proving that he did not build or improve for purpose of sale.). QTy. B FLOOD TONE APN jL as owner of the property,am exclusively contracting with Ikensed PERMIT I ANCE contractors to construct the project(Sec.7034,Business and Professions Code: The Contractor's License Law does not apply to an owner of property who m- W ilds or Improves thereon, and who contracts for such plojects with a ALTER-D &V - i IN= licensed pursuant to the Contractors Limns Law. BACKFLOW DEVICE FEE SUMMARY RYam exempt under See B&P C for this reason Owner nate DRAINS FLOOR GCON D. AR ,COD. ARY Y_ N_ WORKMAN I have aNSATION DECLARATION RFGFTPr p lry�,�1I hereby WORKMAN that 1 have a cenfifificattISATIOe D Consent to self-Insure,ora FO(7l1RFS PER TRAP SCHOOLTAX Y N rehlflote of Workers Campematlan I�uunnre ora certified copy thereof(Sec. RECERsT Y 3800,Ub C.) GAS EA.SYSTFM-1 INCA 0UTLE75 SARK FEE Y N RING rY Polity Y GAS EA.SYSTEM-0EA)V£R 4( BUILDING DIVISION FEES MCertlBed copy b MCertitied copy V filed with herebyte GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE the city inspection division.ity CERTIFICATE OF E%RMPTION FROM WORKERS' GREASE TRAP, PAID I COMPENSATION INSURANCE SEWER-SAFIHARY-STORM EA.200Ff. Date Reeel t# frhissection need not be completed tithe permit Is forom hundred dollars (5100)-eless.) WATER HEATER W/VENT/EECTR ENERGY FEE Y_ N_ I mdlfy that in the performance of the work forwhich this permit is burned, I shall nut employ any person In an ner so as to become subject to the WATER SYSTEM/TREATING workers'Compensation]aw. rnmla.Date PAID C' Z Appllant fiaNEW RESIDENTIAL PLMB. SQ-Fr. [Tate Remi t# Z O NOTICE TO APPLICANT.If,after making this Certlte of Exemption, should become subject to the Worken'Compevation provisions of the Labor TOTAL: Code,you=at forthwith comply with such provisions orthls permit shall be W > deemed revoked. 6UI DING 1 0 CONSTRUCTION LENDING AGENCY SEISMIC FEE a J EL Iherebyaf nothatthere ba costactio Icndingagency for the perform- TOTAL ELECTRIC FEE 0 . 7 Z once althe work(or whkhthb per ed(See 3097,CIv.CJ 02 Lender'.Name PLUMBING FEE U. 1 LendersAddreas Qn. MECHANICAL PERMIT FEE MECHANICAL FEE OO ]certifythat]have read thbappliatlonand statethat theabove ln(ormatlon fl Isommot.l agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID: } relating to building construction,and hereby awhoriu mpresentatives ofthis I.. N city to enter upon the abovo-mentioned property for Wpection purposes. ALTER OR ADDTO MECH. ? (we)agree to save,indemnify an d keep harmless the Ciny of Cupertmn Date Receipt# V against liabilities,judgments,cnmsand expenses which may in anyway accrue AIR HANDLING UNIT CTO 10,000 CFM) SUBTOTAL: against said City in consequence of the granting of this permit. AIR HANDLING UMT(OVER tO,ODOCIiM) CONSTRUCTION TAX Sigruturc of Applicant/Contractor Data D(HAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applies rat or future building occupant store or handle hatardous HEATING UNIT(TO 100,000 BTU) Date Recei t# material as defined by the Cupertino Municipal Code Chapter 9.12 and the .�a� n�I Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: Lyes�4T ❑ Yes No Will theappllant or nambuildlegompantusecqulpmeromdevices VENTILATION EAN(SINGLE RESID) ISSUANCE DATE which emit harardous air contaminants as defined by the Bay Area Air q Quality Ma agement District? BOILER-COMP DHP OR I00,IX0 BTU) P A1 4Y.n II[[.�No have read the huarri ua.maledals requirements ander Ghaptm 6.95 of BOILER-COMP(OVER 100,000 BTU) {fig 9 r� the Ca lRorola Health&Safety Code,Sections 25505,75533 and 25534. 1 MAR ^� 199L understand that tithe building does not currently have a tenant,that it b my NEW RESIDENTIAL MECH. SQ.FT. responsibility to notify the ompant of the requirements which most be met prti/oorr to Issuance of aa/u Ificatte ooff Ompantcy. a� n7 C y p. CL fL _112. `res/kft�ll 44 :WI'�` Y r CUr tn-L C I ner or au tired agent Dat ISSUEDBY:TOTAL: OFFICE COPY