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24406 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BujBuilding Address:lldln Pmcr'demHlcatl � ve Q�pe�i - PF7tMITNO,Z4406 nen am: lUZ ' one: - SUBMITTAL CITY OF CUPERTINO-BUILDING DIVISION ^ C' C°^endOlaName: _ ue.N APPLICATION /PERMIT / [s B1IILDING-ELBCTRICAL-PLUMBING-MFf_HAMCAL CA RY CONTROL M Architect/E,gimer. Lic, o. QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address:PjO — S P PERMITISUANCE ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION I hereby affirmthat l are licensed under provisions of Chapter 9(oommenc. APPLIANCESRESIDENTIAL JOB DESCRI'TION ingwilh Seat1on7000)ofDiW9.3o(the Buslnessand ProfesNomCode,aod my / �/�• licenseis InfuBf and diedic.#'��yS� PANELS tC l � 9 V a-7 LicenseOt= LICK 111 V Date Contractor T 2011000 AMPS UP TO 2DOANTS ARCHITECTSDECLARATION Q�u aO Zp ]understand my plain ahaB be used vpublic records. OVER 1000 AMIPS / rf(N•'fpaPDR jR� -g/SQ.FT. E d Licensed Professional SIGNS ELECTRICAL Llppp�_p 1'Vg rI GGGG 6 OWNER-BUILDER DECLARATION YI P q II T E R IJn� SPECIALCB6CUIT/MLSC V LLL,��� p, owing r act n.(Sect l amexempt(romthe d Professim icanse,mince LawAny for the F�.. following permit w estrum and Pimprove, Code:Mycityor TEMP METER OR POLE INST. 1" ceuntywhich requlrnaperrtdttommlmcL alter,improve,demol4h,orrepalr v i nystmd mpriortoift Wuamc aL°requimatheappUmntfineuchperMtto POWER DEVICES AT to - file a signed statement that he it licensed pursuant to the provisions of the Conlnetor's License Law(Chapter 9(commencing with Section 7000)of Divi- BOJ Non 3 of the Business and Professions,Code)orthat he V SWIMMING POOL ELECTRIC exempt therefrom and r•� VALUATION OO the bask for the alleged exemption. Any violation of Section 7011.$by any OUTLETSSWITCHESFlXTURES D O appBcantfora permltsubjecistheapplicanttoacivll pemityofn°troorethan JJ S D $ five hundred dollars($5M. NEWRESIDENTIALELECTRFT. ❑1,as owner of the property,or my employees with wages as their sale STORE LN TYPE CONSTRUCTION compereation,will do the work and the strvdure it not Intended or offered for psa1e(Sm.7064,Businessand Professions,Code:The ContranoYa Llmme Law ( $$ does not apply to an Owner of property who builds or improves thereon,and CICC.GROIIP RES.UNITS 5; who does such work himself.,thr°ugh Nsown employces,provided that such Improvements are nut Intended proffered forole.If,however thebuilding ue TOTAL: 1mpmvementbsaldwithinomyearofmmplelb theowner-bu0derwlllhave t)Et¢uden of provingthat he did rant build or Improve for purpose ofol°.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN "4 as Owner of the property,am exclusively contracting with licensed contractors to construct the projectt(Sec-7066,Business and Professions Code: PERMIT ISSUANCE The Contractors License Law does not apply to an owner of property who Wild. ALTER-DRAIN AVENT-WATER MA) or Improv.thereon, contracts ch theren,and who contfor supeo)ects with a FEE SUMMARY cgB�don(s)Remand pursuant to the Contractors License Law. BACK FLAW PROTECT.DEVICE U I am exempt under Sec B k P C for this reason Owner Date DRAINS FLOOR ROOF,AREA,OOND. SANITARY RECFIIT N • WORKMAN COMPENSATION DECLARATION 0m 1 hereby affirthat I have a certificate of consent to self-Insure,or FD(TT]NFS PER TRAP SCHOOL TAX Y RECEIPT N NN certificate o(Workersw 'CompeHon Insurance or a certiied ce copy thereof(S . CAS F.A.SYSTEM-1 ING40[TILE(S PARKFEE Y N 3800,Lab C.) RECEIPT N Policy p Com any GAS FA.SY577MAVFR4(FA) BUILDING DIVISION FEES ECedtfied copy is hereby furnished. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE Certified copy k filed with the city inspection dlvlslon. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 20IFT Date Recel t# (Chia section need not be completed Bthe perm0 bforom hundred dollars (S100)teless.) WATER F{FA77R W/VENT/m cr.I.R ENERGY FEE Y_ N_ I unity that In the p rveo oft ework4 he file pertNtll cued, I shall notemploya a d a mann o eco, to the WATER SYSI.EM/•TREATING Workentcmpen o I I at PAID 1 O Z Applicant NEW RE9DENTIAL PLMB. SQFf. Date Recef t# a D NOTICETO LICANT:ILa per kin'( b rtl( Ot Exemptiogyou should become subject to the Workers'Campemt vislomofthe Labor TOTAL: N Cade,you moat forthwith comply with suchprovlab ar this pemdt shallbe BUILDING -� W 7 deemed revoked, CONSTRUCTION LENDING AGENCY SEISMIC FEE S Ihereby afflunthat there be mmtmction lending agency forthe perform ELECTRIC FEE 7 Z an ce oftheworkforwhichthbpert bees MTn.3097,Clv.C.) TOTAL: 52 Lender's Name PLUMBINGFEE H Under's Address QTY. MECHANICAL PERMIT FEE O W bmIcertifythat l have readthbapplicatlonovelnforrtutl° andsntethattheab ^ MECHANICAL FEE CL med.Iagree tocomply with all city and county ordinances and Yate Iowa PERMIT ISSUANCE FEES PAID: N relating to building construction,and hereby authorize representatives ofth)s cit to entero upon ve-me done pro fe'rlm len ALTER OR ADD TO MECH. Z y pO per')' PM p"rp0°G°' Date Receipt# (We)agree to ,Inde fy d kee harmless the City of Cupertino V -BeWtllabNtle d and nseswhlchmayinanywayamme AIRHANDLINGUMT(TO10,000CFM) SUBTOTAL: against said a of a got pemnit CONSTRUCTION TAX. NR HANDLING UNIT(OVER 10,000CFhf) Sigodf reof Appgcant/Contractor Ekri EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building arvpant store or handle hassrdous HEATING UNIT HO 100,000 BTU) Date Reeel t# material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Healthand Safety Code Spins 25532007 HEATING UNIT(OVER 100,000 BTU) TOTAL: ❑ Y. No Willtheappliox or rebuilding arvpantuo equipment or devious VFNRl.AT10N FAN 6INGLE RFS(D) which eISSU�AN EDITEcroft harardous air contarnrents as defined by the Bay Area A4 • Quality Management Dist 2 BOILER-COMP OHPDR 100,000 BTU) Yes No Ihave read the haxa auamaterlabrequirementsunderChapter6.95of BOILER-COMP(OVER 100,000 BTU) 28 1992 the California Health k SafetyCode,SMW.25505,25533 and 25536. I OCT undentandtluti( he Nildingdon mmrrently veatenanLthatltboy NEW RESIDENTIAL MECH. SQ.FT respomibilily t the p aft reqs, which must be met prior to be. rat f a 0111 or VUY CRI 1110 ora d en Date TOTAL; OFFICE COPY