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23970ZZ I.. � 5 W a - :)Z U2 LL ~ OW } a W Z U - APPLICANT TO FILL IN INFORMATION WITHIN RECD LINES -- USE BALL POIN' >,:.: Building Project Identification _ Building Address: 'a0 6,/�c 4,14 IC PERMIT NO. 23970 wnersName: A TIO BMI A ACITY :Phone: OF CUPERTINO-BUILDING V SION APPLICATION / PE IT BUILDING -ELECTRICAL -PLUMBING HAMCA �^ontractor'sName: No: CA • ' RY chitect/Engineer: Lic. No: Q ELECTRIC P R BUILDING PERMIT INFO PLUMB M Address: � ❑ ��♦♦♦ III PERMITISSUANCE `r LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (comment- ing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full e d effect. Licen Class Lic. # APPLIANC SI L P OB pFSC: 0�� f Date Contracto ARCHITECTS DECLARATION I understand my plans shall be used as public records. Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Section 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair `� ' • ' 201-1000 OVER 1000 SQ. Fr. FLOOR �` $/�'' SIGNS ELEC L IFLSPECIALCIR ISC TEMP. METER LETNST. any structure prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Divi- sion 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by a applicant for a permit subjects the applicant to a civil penalty of not more than—�vVV five hundred dollars ($500). ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law POWER DEVICE SWIMMIN ECIRIC ZC OUTLE 'SWITCHESFIXTURES VALUATION M_ NEW IDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION does not apply to an owner of property who builds or improves thereon, and who does such work himself orthrough hisown employees, provided that such 0 S _ . �•� MI improvements are not intended or offered for sale. If, however, the building or improvement is sold within one yearof completion, the owner -builder will have the burden of proving that he did not build or improve for purpose of sale.). ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such pipjects with a contractor(s) licensed pursuant to the Contractors License Law. E]I am exempt under Sec. B & P C for this reasonOUTSIDE T i 7A �' L TE QTY. PLUMBING PERMIT PERMIT ISSUANCE•/ ^' ALTER -DRAIN & VENT - WATER (EA) FEE SUMMARY BACK FLOW PROTECT. DEVICE DRAINS- FLOOR ROOF, AREA, COND. SANITARY Y N_ RECEIPT N Owner Date WORKMAN COMPENSATION DECLARATION JI hereby affirm that I have a certificate of consent to self -insure, ora FIXTURES- PER TRAP SCI-i00L TAX Y_ N RECEIPT # GAS EA. SYSTEM -1 INCA OUTLETS PARK FEE Y N RECEIPT # .ertificate of Workers' Compensation Insurance ora certified copy thereof (Sec. 3800, Lab C.) Policy # _ Cny GAS EA. SYSTEM -OVER 4 (EA) BUILDING DIVISION FEES FTertified copy is hereby furnished. ❑ Certified copy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE GREASE TRAP CERTIFICATE OF EXEMPTION FROM WORKERS' PAID SEWER -SANITARY -STORM EA.200FT. COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Date Applicant Date Recei WATER HEATER W/VENT/ELECTR ENERGY FE N o5 PAID ate Recei t# WATER SYSTEM/TREATING NEW RESIDENTIAL PLMB. SQ.FI•. NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor TOTA • Code, you must forthwith comply with such provisions or this permit shall be BUI G FE S I FEE IC deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the perform- ante of the work for which this permit is issued (Sec. 3097, Civ. C.) sAddr Lender's Address Lender's I certifythatI have read this application and statethatthe above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this cit to enter upon the above-mentioned property for inspection purposes. y P P PertY P PrP° TOTAL: L BING EE �• MECHANICAL PERMIT FEE ME ANI L FEE � PERMIT ISSUANCE FEES PAID: Date Receipt# ALTER OR ADD TO MECH. (We) agree to save, indemnify an d keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in anyway accrue against sa' in cons a anting o is permit. /' pry %�� v AIR HANDLING UNIT (TO 10,000 CFM) It SUBTOTAL: AIR HANDLING UNIT (OVER 10,000 CFM) CONSTRUCTI TAX Sign re of Applicant/ ont ctor Date EXHAUST HOOD (W/DUCT) CONSTRUCTIO TAX PD: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous HEATING UNIT (TO 100,000 BTU) j _ Date NAI material as defined by the Cupertino Municipal Code, Chapter 9.12, and theHealth and Safety Code Section 25532(a)? ❑ Yes N No Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District? Yves ❑ No read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533 and 25534. I understand that if the building does not currently have a tenant, that it is my responsibility to notify the occupant of the requirements which must be met HEATING UNIT (OVER 100,000 BTU) T VENTILATION FAN (SINGLE RESID) ISSUANCE NATE BOILER -COMP (3HP OR 100,000 BTU) BOILER -COMP (OVER 100,000 BTU) NEW RESIDENTIAL MECH.—SQ—FT. prior to issuance of a Certificate of Occupancy. ISSUED BY: Owner or authorized agent Date�,.. T OFFICE COPY