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23515 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building project Identification tl - Budin�ddreu�j : [" PERMIT NO. Muse; 23515 APPLICATIO I IAL DAM Rav uE.L.Er _ CITY OF CUPERTINO-BUILDING DIVISION _ con ctar'.Name: _ Lk.Nm APPLICATION If PERMIT 4rIeS �L/rsI SON gU LDING-E ECTR CAL PLUMBINGMEC4 AMCAL CATEGORY CONTROL# rchiteet/Engineer. Lk.No: 3 LN CSN` ' eo' QLY ELECTRICPERMIT FEE BUILDING PERMIT INFO Addros: te! �- `�. eery°j� I'ERMITISSUANCE ,/�� LH LICENSED CONTRACTOR'S DECLARATION I hereby affirmthat l am Ikensed under Provldonsof Chapter 9(comucco APPLIANCES RESIDENTIAL .JOB DESC N in8`th&e on7000)ofDlWsim3ofthe Businemand PmfemionsCodgmd my license I.In fou form and elect. - PANELS . LimneeC as saes# J,z g Date Contractorrava ARCHITECT' RATION 201-10DOAMPS J/ ^0 CZO I understand my pbmu shall be used u public records.' OVER IOW AMPS SQ.FT.FLOOR AREA $M.FT. PEEddill d 1, Licensed Pmfeplovl SIGNSELECTRICALIV G- OWNER-BUILDER DECLARATION SPECGLCIRCf11T/M1SC Z y. I hereby afflrmthat I am exempt fromthe Commerce.License Law for the J�� O OL F rn following reawn.(Section Tall S,Businessand PmfmiOm Code:Any city or / p� .G7J countywhkhmquimapermlttomrotrucyalter,impmw,demolbh,orrepair �P.METER OR POLE INST. y < anystmctum Prlort0lbismame,alnoreWu theappgcantforsuchpermltto POWER DEVICES K U Ik a stgnad statement that he is Ikensed pursuant to the provbiom of the 3rj Contractors License LAW(Chapter 9(commencing with SeRbn 7000)of Divi- SWIMMING ft70L ELECTRIC eton3ofthe Budomand PrafessbmuCode)orthathebcumpl thercfromend / VALUA]]ONd O she basis n for the alleged jemathea. Any violation of Seaton cm by any OUTLETSSWITCHFSFIXTURPS Z (l •--a ®® appliant(ora permit aubjectetheapplkanttoativll penaltyof na more than ( C LasOwner ll of property,ormyemployeeswith Wages or NEW RESIDENTIAL ELFCTR_SQ}T. STORIES 'TYPE CONSTRUCTION , Compensstlon,Business ahe nd and lhes Code:Th not Intended or m.L for / O vie(Sec apply to abieas el f pmpc ty Code The Contractors LIcave Law �?a; does not apply to w ownel of pro ugh his Who Wilds wnempor improm,idedrmR and such who doasuch w .&meelorthrough hleow;ae.lf yee;pr,theb ildingor OCC.GROUP RFS lWT15 improvementsarenot Intendedprofferedforeak.If,however, Elder Wingor T improvement b wld within one ycaro(campletloM the owner-mgderwill have tIA-Ilunlen of pmving that he did net build or Improve for purpose ofxk.), QTy, PLUMBING PERMIT FEE LJ L as owner of the property,am exclusively contracting with Ikensed FT.00DZONE APN contractors to construe the project(Sec,70K Business and Professions Code: PERMIT ISSUANCE The Commerce.Lt..Law does na apply to an owner d property Who Wilds or Improves thereon, and who contacts Ice such Ptojecta wfth a ALTER-DRAW&VENT-WATER(EA7 o�R[�actor(s)licensed pursuant to the Contractor's Lim..Law. FEE SUMMARY I_J I am exempt under Sea B&P C for this reason BACK FLAW PROTECT.DEVICE EEES • Owner nate DRAINS FLOOR ROOF,AREA,COND. OA IJAKY Y N WORKMAN COMPENSATION DECLARATION RECEPI'k QI hereby affirm that I have•oertlfiam of consent to self-Ince,or FIXTURES'PER TRAP SCHOOL TA% Y N aeilateofWorkerd CemPevanon lrsursna cracartlfled mpythereoffSec. - RECEIVE It 3800,olicyN CJ GAS EA.MrEM•I INCA OUTLETS PARK FEE Y_ N— Co RECEIPT# Com any GAS-EA.SYSI'Eht-OV[iRdIRA) BUILDING DIVISION FEES �CenNed copy V hereby furnished. �Certified copy bfiled With the city Inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE VrZ CERTIFICATE OF I%EM PTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE (Thissection need no becompleted ifthepermlt lsforonehundred dollars SEWERRSANTTARY-STORM FA.200FT. Date Recei tic (Si W)orfess.) ENERGY FEE Y N Isnot thatIn oy he my any of he manner kan as whichthis permit wb*dissued,the WATER HEATER W/VENT/E.FLTR �U M 1 shall not employ wy person in any nunner.t as to t=ame subject to the T e Worlicant cam nv o(GII(pmis.Date _ L WATEpSY'"1Fl1/LRE171NG PAID �/V' 767E 0 Applicant� �. Z 0 NOTICE 7u7(PPLTCANT:lf,aftermakingthb Ceeifkate of Exemptlon,yw NEWRESIDENLIALPLMB. SQjrE Date Recei t# N should become subject to the Workers'Compensatlon pm,,il.m of the Labor TOTAL: s Code,you resat forthwith comply With such provialos orthbi perms shall be IS LU j deemed revoked. ' U O O CL CONSTRUCTION LENDING AGENCY SEISMIC FEE I hereby a(firmthat there b a construction lending agency for the perform. !FEES RIC FEE Z ana ofthework forwhlch this permit b issued(See 309'/,CIv.C.) �+ V O Lenders Name PLUMBING FEE U. U Lend=r tAdareu QTY. MECHANICAL PERMIT FEE ANICAL FEE O W Icenl(yshatl havereadthbapplicaln an dalatelhattheabweinfomuHm 6 iscorrect.I agree to comply with all city and county ordinances and gate laws PERMrrISSUANCE AID: �. N relating to building comutruclon,and hereby authorize representativei of thisZ city to enter upon the above-mentioned property fm Wpection purposes. ALTER OR ADDTO MECH.(We)agree to save,Indemnify an d keep harmless the City of Cupertino te ReceitN agaWtBablbtia,judgments,amtsandexpenvswhkhmaylnanywayam a AIR HANDLING UNIT(rO I%0DO CFM) SUBTOTAL• against said City In comequeme of the granting of this permit. AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX Sig......ppucam/Contractor HAZARDOUS MATERIALS DISCLOSURE Date IXFIAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: Will she applicant orfutme building om.pant store or handle havarcious HEATING UNIT(TO 100,000 BTU) Date material..defined by the Cupertino Mu nitlpal Code,Chapter 9.12,and the _ Recei til Healthand Safety Cade$e 25532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: ❑Yn ,1��'fcx�n WOlthe epplam or ram building occupant use equipment or devlas VENTILATION PAN(SINGLE RLSID) t$rjUANCE DATE Which am t hazardous air contaminants as defined by the Bay Area Air (mV , . Qu Iity Mavgement IXstrlo BOILER-COMP OFI'OR 100,000 BTM 4have read the hazy o..materials requircmenbunder Chapter6.95 of BOILFR-OOMP(OVER 100,000 BIM ry :rr the California Health&Safdycode,Sections 25505,25533and25531, I y understand that lfthe building dues not currently have a tenant,that it b my NE'WRESIDENTIALMECH. SQ FT 4119 .� mponsfbllity to notify she occupant of the requimmems which rtwat be met . •/OF.C�F Z9 priors in i euance of a Certificate of Occupancy. s/4? Owner or authorized agent Date .ro ISSUEDBY: OFFICE COPY