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24387APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT.PEN ONLY Butirling Protect Identification Building -. PERMIT NO o 2 4 3 8 7. yy s amu: G. I c t""nr. Namv:: LIe. N°: APPLICATION / PERMIT VAZ- BUILDINGQ,ECTRICALPLVMBINGMECHAMCAL CATEGORY CONTROL M ' Architect/Engineer. Lk. Nm: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address PERMITISSUANCE ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION APPLIANCES -RESIDENTIAL I hereby affirm that l am licensed under provblons of Chapter 9(commenc. IngwlthaSsecon 7000) of Division 3ofthe Busiruss and ProfessionsCode,and my license Is in fe to= and effect. licensClasss rce Lif ee PANELS JOB DESCRR'TION 1 Date Contractor UP TO 200 AMPS ARCHITECT'S DECLARATION 201-1000 AMPS OVER1000AMPS SQ. FT. FLOOR AREA $/SQ. FT. I understand my plane shall be used as public records. ' Licensed Profeselmrel SIGNS ELECTRICAL - © 9 N OWNER -BOLDER DECLARATION [ hereby af... (Seal nmexempt foramthairs., C Prefe dmu C use law for the following reuon. unction rn Ht t- Buslnese and r, (p a Code: Any cep or countywhkh requlreeapemNttocoutract, alter,lmprove, demoWh, arrepalr anystm=mpAortolbcewance,aisorequcrestheappli=tforsuehper tto file a signed statement that he is licensed pursuant to the pimbioru of the Contractor'sLicense Law (Chapter 9(commencing with Seaton 7000, of Divi- abs 3 of the Bushes.and Profeulora Code) or that he is exempt therefromand the basis for the alleged exemption. Any violation of Section 7031.5 by any apphcantforapermitmbjecletheapplicanttoadviipenaltyofnotm mthan ve hundred dollars($500). as owner of the property, or my employees with wages as their sole c pensat(omwdldolheworl:andthestmeturebnacntendedorofferedfor , `a , kLE , I WALLIATION SPECIAL CIRCIAT/MLSC 7'EMP.METFR ORPOLE INST. POWER DEVICES t SWIMMING POOL ELECTRIC OUILETSSWI1CIiESFIX'IVRFS NEW RESIDENTIAL ELFGTR SQ.FT. - STOR[(S TYPECONSMUCTION' (Sec. 7044, Business and I'm(ma a. Cade: The Contractors Lt.. Taw does not apply to an owner of property who Wilda or improves thereon, and who does such work hlmselforthrwgh hcsownemployees,provided thatsuch OCC. GROUP RFS. UNITS - Improvements are not intended oroffered forsals. If, however, the W ilding or Improvement bsold Mthinoneyearofcompletlomtheowner-bu0derwlll have ttdZurdenof proving that he did cwt Wild or improve for purpose ofsals.). u I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professlom Code: The Contractors License Taw does not apply to an owner of property who Wad. or Improves thereon, and who such Ispiecte with a �'gR�fanorW licensed pursuant to the Contractor's License Law. LJ I am exempt under See B k P C for this reuon TOTAL: QTY, PLUMBING PERMIT FEE PERMIT ISSUANCE ALTER-DRAIN k VENT -WATER (EA) I FLOODZANE- APN ' gA�p(pV/pgOTECT. DEVICE FEE SUMMARY DRAINS FLOOX ROOF, ARRA, CONTI. FEKTURES'PER TRAPSCI3OOLTAX SANITARY Y_ N_ RFGRB'T R Owner Dare WORKMAN COMPENSATION DECLARATION ❑I hereby affirm that I have a certificate of consent to self-0nwre, or ttrtlRcate of Worksm'CompereaHonlnsurance maartlfkd copythereof (Sec. 3800, Lab C.) 'Pollcyis Y_ N_ RECEIPT al - GAS EA. SYSTEM -1 INC40UTLETS PARKFEE Y_ N RFGEfPN ". Com any GAS EA. SYSTEM-OVER4 MAE BUILDING DIVISION FEES [�Certifed copy is herebyth thecid. Certified copy b (fled with the tlty Inspection divlelon. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE GREASE TRAP CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE s (Thisseecoo neednatbecompleted lfihe permit bforom hundred dollars ($1Wadifyts.) I cenot that employ an person any annex an as t cern pesubjec blued, I soaks not employ any peas In any manner at es to bacons subject to the Workss'Compenation Laws o(Glifomla. Dale Applicant NOTICE co APPLICANT: a after making per Cerbfipro is Exemption, you should become subject to the Work en' Compemaiio porthis p of the Labor Codnor at forthwith comply with such provisions or this permit shall be a«mus revnkea. - - PAID Date Recei t# SEWER -SANITARY -STORM EA. 200FT. WATER HEATER W/VENT/ELRCTR ENERGYFEE' Y N PAID - Date . Recei t# WAT RSYSTEM/TREATING NEW RESIDENTIAL PLMB. SQFT. TOTAL: BU FEE TOTAL: -CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the ptrform- ance of the work for which this permit is Issued (Sec. 3097, Civ. C.) lenders Name Lessers Address I met 1fy that I have read t hb application and stall that the above N ti formaon SEISMIC FEF, ELECTRIC FEE - QTY. MECHANICAL PERMIT FEE PLUMBING FEE MECHANICAL FEE FEES PAID; - Dale Recei pt# is correct. I agree to comply with all tltyand county ordinanasandstatelawaPERMIT relating to Wilding construction, and hereby authorize representativesoftha city toenter upon theab=muntimusl Property fee inspection purposes. (We) agree to seve, Indemnify an d keep harmless the Ctry of Cupertino against liabilities, judgments, cost sandexpemseswhich ay.cems against said City in m ence of tiffanting I� ISSUANCE ALTERORADDTOMECH. 'AIR HANDLING UNIT (To 10," CFM) SUBTOTAL; AIR HANDLING UNIT (OVER 101000 CFM) CONSTRUCTION TAX (App cant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: ' HAZARDOUSMA IALSDISCLOSURE HEATING UNIT (TO 100,WoB'fU) Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.1$ and the Health and Safety Code Section 25532(a)7 El Yea M No Date - Retei [# HEATING UNIT (OVER 100,000 BTU) IOTA �"�' VENTILATION FAN (SINGLE REBID) ISSUANCE DATE P y 0 Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Qualty Management District? , 4Yes n No haveread the haza�ouswteriabrequirementsunderChapter6.95of the Glifernia Health k Safety Code, Sen Ions 25505; 25533 and 25534. 1 BOILER-COMP(3HP OR 100,0M BTU) BOILER-COMP(OVER IW,OW BTU) - NEW RESIDENTIAL MECH. SQYr. understand that if the building does not currently have a tenant, that it is my, responsibility to notify the occupant of the requirements which at be met prior to Issuance of a Certificate of Occupancy. OCT 22 19v Etp IsslT�pl�Yf EiF Cs - Owner or authorized agent Date OFFICE COPY