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24269 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PERMIT hO. LJ 4 2 6 9 Building Address: ,4 - r a one: p p CITY OF CUPERTINO-BUILDING DIVISION- cnpgaan jN.me: Lk.No: APPLICATION /PERMIT JCNt BUILDINGELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROLN Architect/Engineer. 901, Lk.No: QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO'- - AddrusePERSIDISSUANCE El 1:1 � F-1LICENSED CONTRACTOR'S DECLARATION with by affirm Sation7Dthat) iv Bcen3oftheunder provisions I'mCssions odeand my APPLIANCES-RESIDENTIAL JOB DESCRIPTION Ijamse i Semina 7000)01 Divislon3ofthe Businessand ProfesslonsCode,and my license is inw or�and effect. PANELS l , /' it, a Lr�•` \ s Lakrs License Cw LieN � DateContra or �b�� UP TO 2DO AMPS ARCHITECPS DE RATION OVFR10AMPS DOAM �Z [understand my place shag be used upub0<recrnds OVER 1000 AMPS SQ.FT.FLOOR AREA §/SQ.FT. CO �U Licensed Professional SIGNS ELECTRICAL [ D f G LG3 OWNER-BUILDER DECLARATION f ll� fn• S SPECIAL CIRCUIT/MLSC io,,, - owing raflrmthat I ndioo 731.5,Business and Contractor's License Law fort he �'� p n �� U 2 following reason.(Section 7W 1.5,Buslneu and Pro(essiore Code:My city or TEMP MMTR OR POLE INST. b pVII R F ke' county which requircsa permit to construct,alter,berprove,dennlbh,orrepair / ,M�. anystrutture prior to its Issuance,also requlrestheapplicant for such permit to POWER DEVICES /� c. ilk a signed statement that he L licensed pursuant to the provbiom of the V Contractors License Law(Chapter g(commencing with Section 7000)ofDivi. SWIMMING POOL ELECTRIC TOY O sion3 of the Business and Professions Code)orthat he is exempt lherefromand 5 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS-SWITCHES,HXTURES applicant for a permit subjects the applicant to a civil penalty of net more than G=0 five hundred delta.( . ,g. NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION ❑I,as owner of the property,or my employees with wages as their sole Cc¢ compensation,will clothe work and thestructure is not intendedor offered for 9 p sale(Sec.70K Business and Prefesi loreCode:The Contractors License Law does notapply to an ownerof property who buildaor improves therroq and OCC.GROUP RFS.UNITS who does such work himself orthmugh hisown employees,provided that such Improvements arc not Intended muttered forsale.If,however,the building or TOTAL: ' Improvement Lando withinoneyearotcompletlon,theowner-bullderwlil have tht�rden of proving that he did not build or improve for purpose of sale.). QTY., PLUMBING PERMIT FEE FLOOD ZONE APN, u L as owner of the property,am exclusively contracting with licensed PERMRISSUANCE contactorsto constwct the project(Sec.7044.Business and Profemiors Code: Sa The Contractors License law does not apply to an owner of property who Wilds or Improves thereon,and who contracts fee such p�o)ects with a ALTER-DRAIN VENIT-WATER(EM e manp4s)Boensed pursuant to the Contanors License Law. FEE SUMMARY ❑I am exempt under Sec. B&P C for this reason BACK FLAW PROTECT.DEVICE OUTSIDEFEES DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N Owner Date RECEIPT If WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y N EC ❑I hereby affirm that I have a certificate of consent to self-Inare,ora RECEIPT N certificate ofWorkere Compensation Insurance ora mrtBied copy thereof(Sec. GAS EA.SYSTEM-I INCA OUTLETS PARKFEB Y N 3§ DING DIM .. PoligN % GAS EA.SYSTEM-0VERd(EA) BUILDING DIVISION Fr,IS Cam anv Certrfie o L erc tum shed�� Py GREASE/INDUSTAL WASTE INTFRCII'TOR PLANCHECK FEE f1�I,CertJied copy L(fled with the my inspection division. CERTIFICATE OF EXEMPTION FROM WORKERSGREASE TRV' PAID COMPENSATION INSURANCE SEWER-SANITARY-SIORM FA.RAFT. Da[C Recef t# (I'hlssection need not be completed If the perrNt is forom hundred dollars (§100)orleas.) WATER HEATER W/VENT/ELFCTR .50 ENERGY PEE Y_ N_ I mrtily that N the performance of the work for which this permit is Issued, 1 shall not employ any person In any manner so as to became subject to theWATER SYSTEM/TREATING PAID Workers'Compensation Laws of California. Date Z Z NOTICE TO APPLICANT.If,after raking this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FI. Date Recel t# PO should become subject to the Workers'Compensation provisions of the Labor TOTAL: WN Cod,you must forthwith amply withsuch provisions or this permit shall be BUILDING FEE > deemed revoked.CONSTRUCTION LENDING AGENCY SEISMIC FEE aZ Ihereby affirm that there L a corstruction lending agency for the perform TOTAL: alts ELECTRIC FEE 7 ance of the work for which this permit L issued(Sec.3097,C1v.C.) Z V O lender's Name - PLUMBING FEE LL H L eder'aAddress CITY. . MECHANICAL PERMIT FEE MECHANICAL FEE U 1certifythat I have readthisappliauon and statethattheabov,information O W Isconed.Iagree to complywith all city and countyorcllnancesand state laws PERMIT ISSUANCE FEES PAID: 1 relating tobulliing construction,and herebyauthomerepresenlativac4this - F Z city to enter upon the above-mentioned propertyforimpection purposes. ALTERORADDTOMFCH. _ Date Receipt# (We)agree to uve,Indemnify and keep harmles which the Cityea of ayace a AIR HANDLING UNIT(TO 10,000 CFM[ V against liabilities,pigments,nests and expenses which rtuy be any wayacaue SUBTOTAL: rami Citylnmmwu of the graeung of this permit. CONSTRUCTION TAX en — /Qi/y7Q AIR HANDLING UN (OVER 10,01ii 6011ature of Applicant/ tractor t Data J EXFIMJS'r HOOD(W/DUC-D CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will theapplicant or future building t store or handle hazardous HFATINGUMT(TOIOD,ODOBTU) raterkl ns dneo by the Cupertino Municipal Cod,Chapter 9.l Z,and the Date Recef 1# Ikallh and Safety Code Section 25532(a)? HEATING UNIT(OVER]00,000 BTU) TOT ❑Yes - MN. Wli the applicant or future building occupant use equipment cur devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE which cent havrdous air contamlants as detlned by the Bay Arca Air Qaality Management District BOILER-COMP OHPOR 100,000 BTU) . 4 Yui Q Nn haveread the ealth& et m ode,Sectionrcments under Chapter. I of BOILER-COMP(OVQT 11kT,000 BTU) p§ p ' D the Olta nd to Hi if the Safety Code,not eu mendy have tenant, that I f- !9 understand that if the building does not currently have atenanL that ltLmy NEW RISIDPN77AL METH. SQ.FT (T[� responsibility to notify the occupant of the requirements which nwat be met OCT 21 132 prior to issuance of a Certificate of Occupancy. Owner or authorized agent Date TOTAL: ISSUED¢Y' OFFICE COPY