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24172 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY Building-Project Identification PERMITNQ, A Building Address: ernl� \ IGS r2 ner- sName: Phone: APPLICATION SUBMITTAL DATE CITY OF CUPERTINO-BUILDING DIVISION /� f..r- Contractor's Name: Lic.No: APPLICATION /PERMIT ``4r'"' BUILDING-ELECTRICAL PLUMBINGMECHANICAL CATEGORY C G Architect/Engineer. Lic.No: QTY , ELEGTRIGPERMIT FEI ny BUIL N7I P.ERIi IT INFO Address: - -- PERMITISSUANCE El El El LICENSED CONTRACTOR'S DECLARATION I hereby affirm that Lam licensed under provisions ofChapter 9(comment- APPLIANCES-RESIDENTIAL JOB DESCRIPTION ingwith Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect. PANES ®� License Class Lic.N L. Date Contractor UP TO2 ARCHITECTS DECLARATION 201-1000 AMPS P4 0 1 understand my,plans shall be used as public records. OVER 1000 AMPS SQ.FI'.FLOOR AREA $ Z w Licensed Professional SIGNS ELECTRICAL �9 LA7�_L Q P. OWNER-BUILDER DECLARATION 7 Loor— cn SPECIALCIItCUIT/MISC OR F, I hereby affirm that I am exempt from the Contractor's License Law for the //��-- 0 W following reason.(Section 7031.5,Business and Professions Code:Any city or ®y�4 / Z N W G 81 TEMP.METER OR POLE INST. vv countywhich requires a permit to construct,alter,improve,demolish,or repair a any structure prior to its issuance,also requires the applicant for such permit to POWER DEVICES � � �O Vfile,a signed statement that he is licensed pursuant to the provisions of the 0 u,h Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- 3 O m sion3 of the Business and Professions Code)or that he is exempt therefrom and SWIMMING POOL ELECTRIC VALUATION Q I the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS-SWITCHES-FIXTURES applicant fora permit subjects the applicant to a civil penaltyof not morethan o O five hundred dollars($500). TYPE CONSTRUCTION N F-]I,as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELECTR SQ FI. STORIES compensation,will do the work,and the structure is not intended or offered for qsale(Sec.7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES.UNITS c who does suchworkhimself orthroughhis own employees,provided that such improvements are not intended or offered for sale.If,however,the building or TOTAL: improvement is sold within one yearofcompletion,the owner-builderwill have �. the burden of proving that he did not build or improve for purpose of sale.). (�'py;�""� P .�€TMBL TI'ERI1$T .?FEE'; - FLOOD ZONE APN ❑L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE 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 ALTER-DRAIN&VENT-WATER(EA) builds or improves thereon,and who contracts for such projects with a contractor(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECTDEVICE ❑I am exempt under Sec. B&P C for this reason . OUTSIDE FEES Owner Date Mg DRAINS-FLOOR,ROOF,AREA,COND. SANITARY . Y N gC�rr q WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y .N ❑I hereby affirm that I have a certificate of consent to self-insure,or a RECEIPT N certificate of Workers'CompensationInsuranceoracertifiedcopythereof(Sec 3800,Lab C.) GAS EA.SYSTEM-1INCA OUTLETS PARK FEE Y N_ Policy N RECEIPT# GAS EA.SYSTEM-OVER 4(FA) Com any BUILDING DIVISION FEES Certified copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE ❑Certified copy is filed with the city inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE (Phis section need not be completed B the permit is for one hundred dollars SEWER-SANITARY-STORM EA.200FI'. Date Rec ' t ($100)or less.) ENERGY FEE Y N I certify that in the performance of the work for which this pemilt is issued, WATER HEATER W/VENT/ELECTR I shall not employ any person in any manner so as to become subject to theWATER SYSTEM/TREATING 0 ter Workers'Compensation Laws of California. Date PAID z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FI'. Date ' 0 Applicant , ecc� Z N 0 should become subject to the Workers'Compensation provisionsof the Labor TOTAL: Fn Code,you must forthwith comply with such provisions or this permit shall be 'BUILDING FEE W > deemed revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE d 0 1 hereby affirm that there is a construction lending agency for the perform- TOTAL: ELECTRIC FEE Z ante of the work for which this permit is issued(Sec.3097,Civ.C.) O O Lenders Name " 777 PLUMBING FEE LL H Lenders Address QTY,„ M1EHAItiIIG21L PLRIIT , `.'> MECHANICAL FEE ® W I certify that I have read this application and state that the above information IL is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID: IL relating to building construction,and hereby authorize representatives of this I... city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt# V against liabilities,judgments,costs and expenses which may in anywayaccrue AIR HANDLING UNIT(O 10,000 CFM) SUBTOTAL: against said City in consequence of the granting of this permit. AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recel t# material as defined by the Cupertino Municipal Code,Chapter 9.12,and the _ Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: ❑ Yes b No Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE -which-emit-hazardous-air-contaminants-as-defined-bythe-Bay-Area-Air ----- -- - Quality Management District? BOILER-COMP(3I-IP OR 100,000 BTU) ❑YesNo I have read the hazar ous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)• 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 NEW RESIDENTIAL MECH SQX-T responsibility to notify the occupant of the requirements which must be met prior to issuance of a Certificate of Occupancy. Owner or authorized agent Date TOTAL: ISSUED BY: OFFICE COPY APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project identification PERMIT NO. Building Address: s�� 24173 caner s Phone: APPLICATION SUBM11 AL DA CITY OF CUPERTINO-BUILDING DIVISION - Contractor's Name: Lic.No: APPLICATION / PERMIT BUILDING-ELECTRICAI,PLUMBING-MECHANICAL CATEGORY Architect/Engineer: Lic.No: U'Brf'T�QR� QTY ELECTRIC PERMIT FEE BUILDING PERMIT IN66FO Address: - PERMITISSUANCE ❑ ❑ ❑ ''............. LICENSED CONTRACTOR'S DECLARATION Ihereby afffrmthatIamlicensedunder provisions ofChapter9(comment- APPLIANCES-RESIDENTIAL JOB DESCRIPTION In cense i Benton force of d effeon3 of the Business and ProfessionsCode,and my license is In full force and effect. PANELS ''... License Class Lic.q Date Contractor 200 AMPS ARCHITECT'S DECLARATION 201-1000 AMPS qqq ouf]O I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SSQ.FFJT. Z 6 Licensed Professional SIGNS ELECTRICAL ®Orp ® V Q cW. OWNER-BUILDER DECLARATION t��.J',)J mSPECIAL CIRCUIT/MISC t, I hereby affirm that I am exempt from the Contractors License Law for the Z Z_ pp following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP.MEI-EK OR POLE INST. W county which require s a permit toconstnict,alter,improve,deniolish,orrepalr q a any stmctum prior to Its issuance,also requires the applicantfor such perrrdtto POWERDEVICES '''............ Ufile 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- VALUATION 3 ti P g SWIMMING POOL ELECTRIC O� sion3 ofthe Business and Professions Code)or that he is exempt therefrom and E the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFD(TURES applicant fora permit subjects the applicant to a civil penalty of not more than l ®® a o five hundred dollar pr. SQ. STORIES TYPE CONSTRUCTION m m �I,as owner of thehe property,or my employees with wages as their sole NEW RESIDENTIAL ELECTR FT. >' compensation,will do the work,and the structure is not intended or offered for qsale(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 whodoessuchworkhimself orthrough his own employees,provided that such OCC.GROUP RES.UNITS improvements are not intended or offered for sale.If,however,thebuilding or TOTAL: improvement is sold within one yearofcompletiontheowner-builderwlllhave the burden of proving that he did not build or improve for purpose of sale.). QTY., PLUMBING PERMIT FEE. FLOOD ZONE APN ❑L as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.70JA Business and Professions Code: PERMIT ISSUANCE The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) builds or Improves thereon,and who contracts for such p{ojects with a FEE SUMMARY contractor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE EJI am exempt under Sec. B&P C for this reason SID FEE Owner Date DRAINS-FLOOR,ROOF,AREA,COND. SANITARY Y N__._ RECEIPT q WORKMAN COMPENSATION DECLARATION �.�ES�.�, SCHOOL TAX Y_ N_ ❑I hereby affirm that I have a certificate of consent to self-insure,ora RECEIPT q certificate of Workers'Compensation Insurance or a certified copy thereof(Sec. GAS EA.SYS1"EM-lINC.40U1LEI'S PARK FEE Y_ N_ 3800,Lab CJ RECEIPT q Policy q CoffanGAS EA.SYSTEM-OVER 4(FA) Com any BUILDING DIVISION FEES Certified copy is hereby furnished. . GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE Certified copy i9 filed withh the the city inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recei t# (This section need not be completed if the permit is for one hundred dollars ($100)orless.) WATERHEATERW/VENT/ELECTR ENERGY FEE Y_ N_ 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 WATER SYSTEM/TREATING Workem'Compensation Laws of California.Date PAID Z Z Applicant NEW RESIDENTIAL PLMB. SQ FT. Date Recei t# O NOTICETO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Workers'Compensation provisions of the Labor TOTAL: CCfA Code,you must forthwith comply with such provisions or this permit shall be BUILDING FEE W > deemed revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE f1 o I hereby affirm that there is a construction lending agency for the perform TOTAL: ELECTRIC FEE Z ante of the work for which this permit is issued(Sec.3097,Civ.C.) PLUMBING FEE L) Lender's Name - LL F- Lender's Address QTY. ` MECHANICAL PERMIT- FEE MECHANICAL FEE OW IcertlfythatIhavereadthisapplicationandstatethattheaboveinformation 4. is correct.I agree to comply with all cityand county ordinances and state laws PERMITISSUANCE FEES PAID: >. a. relating to building construction,and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt# V against liabilities,judgments,costs and expenses which may In anywayacrnre AIR HANDLING UNIT CIO 10,000 CFM) SUBTOTAL: against said City in consequence of the granting of this permit. AIRHANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX Signature of Applicant/Contractor Date EXHAUST HOOD(W1 DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous HEATING UNIT(IO 100,000 BTU) Date Recej t# material as defined by the Cupertino Municipal Code,Chapter 9.12,and the 00 Health and Safety Code Section 25532(a)? FIFATING UNIT(OVER 1 ,000 BTU) TOTAL: ❑Yes NN. Will the applicant or future building occupant use equipment or devices VEN17LATION FAN(SINGLE RESID) ISSUANCE DATE -- -which emifhazardous air contaminants as defined by the Bay Area Air Quality Management District? BOILER-CAMP(3HP OR 100,000 BTU) ❑ Yes ❑No I have read the hazardous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) 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 NEW RESIDENTIAL MECH. SQ.FT. , responsibility to notify the occupant of the requirements which must be met prior to issuance of a Certificate of Occupancy. Owner or authorized agent Date TOTAL: ISSUED BY: OFFICE COPY