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24075 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY b uilding Project Identification PERMIT NO 24075 Building : ©8 G D� one: APPLICAj CITY OF CUPERTINO-BUILDING DIVISION e: Llc.No: APPLICATION / PERMIT ` BUILDINCILECTRICALPLUMBING.MELHANICAL CATEGORY CONTROL • W:M/Fsginser. LIc.No: BUILDING PERMIT INFO- "QV iwi ELiCTRICPERMUlf '� - "' FEES ' Address RFERMITISSUANCE 1:1 El El LICENSED CONTRACTOR'S DECLARATION I hherebyatbmthat lam licensed underr provisions ovisions of Chapter9(comment Alrlel.7ANCFSRESIDENML^ LOB DF5CRE7ION ingwith SeMon700D)of Diviatan3ofthe Buainessand ProfesdonsCo k.d my license is In full force and effect. PANELS License Clan LION W� �• Date Contractor ARCHITECTS DECLARATION 201-1000 AMPS QaO I understand my plana shall be used a co public records. OVER1000AMPS XI.FT.FLOOR AREA $/SQ.FT. TY Z Licensed Professional SIGNS ELECTRICAL H OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC I„ 3 I hereby affirm that I am exempt fromthe Contractor's License law for the pp p following reason.(Section 70315,Businessand Prof.i..Code:My dtyor eountywhkh requlresa permit tomnstruC,alter,impmwS demoBsh,arrepalr TEMP.MEIFRORNLEWST. ;4 ^J any atruatureprbrto ibiwance,alw eequlrnthe appBcarttlor such permit to POWER DEVICES yd 5 file a signed statement that he b licensed pursuant to the provisions of the S �� Contractors License Law(Clupter 9(commencing with Section 7000)of Dlvl- SWN(MlNG NOL ELECTRIC VALUATION _ 05 aton3ofthe Businenand PrefrssionsCodNorthat hetseaemtpttherefromaed the basis for the alleged exemption. Any vielaHon of Section 7a by any OUTLETSSWITCHI&FD=ES applicant fora permit subjects the.ppU=t to a dvll penahy of net momtNn frvr undred dollar OSM. NEW RESIDENTIAL ELEM SQFT. STORIES TYPE CONSTRUCTION .. 1,as owner of the property,or my employees with wages as their sole compersa ics,will clothe work and the structure is not Intended or offered for t p ss1e&c.7011,Business and Pmfessione Code:The Contractors License Law 3$ don nes apply to an owner of property who builds or lmprovee therein,and OCC.GROUP RFS.UNITS who doessuch work himself nrthrough Msown employee,provided that such imprevemew are nm Intended or offered for ale.If,however,the building or TOTAL improvement bseld within oneyearotcomplalon,the cwocr llcierwW have . ... .. ._... _. 111E.b1rdenot pmWngtha he did rat build crimpreneforpurposeotale.). QTY. PLUMBING PERMITr': � FEE,-' p1.00D ZONE APN �,a owner of the property,am exclusively mntradlng with licensed PERMIT ISSUANCE � ma ars to construct the project(See 7014,Business and Professions Code: The Contractor's Lioness Law don not apply to an owner of property who builds or Improves thereon,and who contra for such with a ALTER-DRAIN&VENT-WATER(EA) ,- oq➢��dorW licensed pursunt to the Contradoes License Law. :FEE'�SUMMARY<i i"a,-3j,"y LJ I am exempt under Sm B k P C for this region RACK FLOW PROTECT DEVICE OurrSIDF_ - Owner Date DRAINS FLOOR ROOF,AREA,GOND. SANITARY RECF4ri'N WORKMAN COMPENSATION DECLARATION pB(TDgEq ppR n(Ap Y N • � SCHOOL TAX 1 hereby affirm that I have a certificate of consent to self-Insure,or RECEIPT N nifiate of Workera'Compensationlaunnx me certtkdcopythemo(6ec. GAS EA.SYST(M-11NG/OUTLET'S PARK FEE Y N 3800,Lab Q RD=Y GO N anGAEA.SYEM-OVER4(EA) BUILDING DIVISION FEES Com y S ST ECertWed copy is hereby furnished. GREISE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE MCrrtlfied copy b tiled with the city Inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SLIDER-SANITARY-STORM EA.20(SeI Date Reeef ted (Thbsectlon need nes be completed R the permit b for arca hundred dollars (5100)erlda) WATER HEATER W/VENT/ET.= ENERGYFEE Y_ N_ I mnifythat Nthe performunmaf the work forwhlch thls pemnt is timed, I shall not employ any person In any manner w as to become subject to the WATER SYSTTM/TREATING PAID Worleri Compenatlon Lawn of California.Data Z O Applicant Date Recei tp Z NEW RE9DFATW.PLMB. SQFT. � hOTICETO APPLICANT, ahermaking Ceatnlrif you should became subject tohe Worers Compensation provisions oftheLabor TOTAL: N Code,you=at forthwith complywlth such provisions orthts permit shall be BUILDING FEE W > dnmed reveled CONSTRUCTION LENDING AGENCY SEISMIC FEE (L G therebyeffirmthetherebaconstructlonlendngagenry for the perfmmo- L. ELECTRIC FEE and,of the work for whkh thb permit is blued(sec.3097,Civ.C.) VO lander.wme - _ .. PLUMBING FEE I- Lender.Address QTY. _.`%MECHANICAL PERMIT 'jFEE , LL U IcenlfythatlhavemdthbappU.tianandaatethattheabove Information MECHANICAL FEE O W (scorned.I agreeto comply with all cityand county ordinancesand state laws PERMIT ISSUANCE FEES PAID: } 1 relating rebuilding construction,and hem6yauthodmrepresentativesofthb (— Z dry to enterupon the above-mentioned propertyforWpectlon purposes. ALTER OR ADD TO MECH. Daft Recei ted (We)agree to ave,Indemnify an d keep harmless the City of Cupertino V against lbbWties,judgment,taadand expenses which may In anywayaccue AIR HANDLING UNIT(TO 10.=CM) SUBTOTAL: .gZainstsai ftyincenuceiru f-the gr ting of this permit.v/b�y AIR HANDLING VNrr(OVER lB,oaa GEM) CONSTRUCTION TAX Sig tura of Applicant/Conrado Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle ha,cardoua HEATING UNIT(70 I OO,ODO BTU) Date Recei t material as defined by the Cupertino Municipal Code,Chapter 9.IZ and the Hahh and Safety Code Stollen 75532(,)7 HEATING UNIT(OVER 100,000 BTU) TOTA ❑Yes LJ No Ill the app hard orTfu m building occupant useequipmrnt or devices VENTILATION PAN(SINGLE RESIT) ISSUANCE DATE which rout haardous air contaminants as defined by the Bay Area Air - Quality Mansgcrecet D strlct7 BOILER-COMP PHP OR I OO,fXD BM ❑Yes No (have read the haramous materials requirements under Chapter.'t93 of BOILER-COMP(OVER 100,000 BM e CaliforniaCthalifornia Health&Safety Code,Sections 25505,2W3 and 7553/.1 �{ r understand that if the building don not currently have a tenant,that it is my NEWRESIDENTIALMECH. SQ.FT AUGesponsibility to notify the occupant of the requirrmens which meet be nod fi prior to issuance of a Certificate of 0owpancy. 6 i9 ,195 Owner.,suthorbed agent Date TOTAL: ISSUED OFFICE COPY