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23096APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification Building Address; PF}MTNO. ' n C © Ol A ` -096 J wnera ams: - one: CITY OF CUPERTINO-BUILDING DIVISION APPLICATION/ PERMIT .. BUILDINGELECTRICALPLUM MBINCMECHACAL' Z—1 3"—' '11 c.n a°:•N.nre: LIc,No: -ed C O Mn Q CATEGORY CONTROLM Architect Lk No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO . Address: ,'. _. PERMITISSUANCE r ❑ i ❑_ LICENSED CONTRACTOR'S DECLARATION I hereby affirm that l am Licensed under provisionsof Chapter 9(commane- i.gwith Section 7000).(Dlvlslon3ofthe Businessand Prole ad...Code,a°d my licensel.Inful res and effect. License Gla LkN Date Contractor -/ APPLIANCES -RESIDENTIAL JOB DESCRIPTION - PANELS 201' 000AMPS ARCHITE ECLA ATION OVERIOWAMPS, •• SQ.FF. OORAREA -S/SQ.FT. I understand my place shall he used as public records. SIGNS ELECTRICAL' Licensed Professional SPECIALGIRCUIT/M1SC OWNER -BUILDER DECLARATION I hereby affirm that 1 am exempt from the Conlractorb License Law for the ' qp,(p METER OR POLE INSf' . following maxer.(Section 70315, Business and Professions Code: Any city or c° untywhichmqulmapermittommtmd,alter,4 pmve,demolbh,orrepair - anystm=mpd.ctoibWuance,aL mqulmtheapplimnH°nuchper tlo file a signed statement that he is licensed pursuant to the provielora of the Contractors License Law (Chapter9(mmmencingwith Section 7W3)of Divi- slon3ofthe Buslnessand Profemiom Code)orthatheisewmptthercfromand POWER DEVICES ' SWIMMING IDOL ELECTRIC- VALUATION the basis for the alleged exemptlon. Any violation of Section 7031.5 by any applicant fora permit subjects the applicant to a civil penalty a ma ".than OUTLETSSWITCHPSFIKTURES ' - ' NEW RESIDENTIAL ELECTR - SQ.FT. five hundred dollars (5.500). . • ' MI, as owner of theproperty, or my employers w h wages as theb sole STORIES TYPE CONSTRUCTION compensation, will do line work and the structure la net Intended or offered for - ale (Sec. 7044 Business and Professions Cade: The Contraaoe. Llceme Taw does not apply to an owner of property who Wilds or Improves thereon. andOCC. who does such work himself orth rough his own employees, provided that such GROUP RES. UNITS - Improveminbarcnotln(ended croftcred for sale. l(, however, the Wilding or Improvement bsold wilhlnoheyaarofcomplellon;theowner-bullderwlll have TOTAL: thil burden of proving that he did not Wild or Improve for purpose of sale.). n L as owner of the property, am exclusively contracting with licensed mntracturs to construct the project (Sec. 7014, Business and Professions Code: QTY, PLUMBING PERMIT FEE PERMRISSUANCE O FLOOD ZONE APN The Contractor's License taw does na apply to an owner of property who Wilds or Improve. thereon, and who mam= for such p m ems with a cgE(lacmrr (el ftompursuant to the Contractor's License Law. LI I am exempt under Sec. B k P C for this reasonOUTSIDE - ALTERDRAIN& VFM- WATER(E-k) ' FEE SUMMARY BACK FLOW PROTECT. DEVICE' DRAINS FLOOR ROOF, AREA, COND. - FIX'NRFS PER IRM - -UQ SANITARY Y_ N-� - - RECEIPT# Owner - Date WORKMAN COMPENSATION DECLARATION ❑I hereby af(Ire, that / have a comflate of consent to self -Inure, ora ce00,IsleC.Woricers'Comperuatlonlvuranceaacenl(hd mpythereof (Sec. Tab C.) SCITppL TAX Y_ N_ RFCI7 NN CAS EA. SYSTEM -I RICA OUTLETS PARK FIT- Y N Polic Policy p - RECEB'I' N GAS EA. SYSTEM-0VER d (FA) Com any BUILDING DI VISION FE ES s tumished. [�Certlfled copy ifiledw �Cerlifled copy V (Tied with the city inspection division. - GREASEANDUSIRLWASTE INTERCEPTOR PLANCHECK FEE - GREASE7RAP' CERTIFICATE OF EXEMPTION FROM WORKERS' PAID SEWER-SANITARY•STORM EA. 20OFT. COMPENSATION INSURANCE ion need na be complHed i(the pemdl is faers hundred dollar R.e Date Recei tp WATER HEATER W/VENT/ELECTR ENERGY FEE Y N ire a100)or les..) I that in which this permit id ll nm employ aeypeiperformance nyt neerwork w res 1 shall not employ any pe n In any manner as as t be bkct to the to the, Workern'Com ration laws of .cola. Date" 3 � WATER SYSTEM/TREATING PAID Applicant rim NOT] C P.Q NT.I,a arms i Exemption, Dale RCceI [:F NEWRISIDENTIALPLMB. :n.FI'. ' ertdlate, of you should become subject to the Workeri Compensation provisions of the Labor TOTAL: Code, you at ion hwith comply with such proxdsices or this permit hall be deemed revoked, LDING FEE _BUT SEISMIC FEE CONSTRUCTION LENDING AGENCY I hereby affirm that there la, aconstruction lendingagenry, for We perfornF arw of the work for which this permit is issued (Sec. 3097, Civ. C.) larder's Name tendce.Adder.. I certifythat] have read this application and statethatthe above Information lscorrea. I agree to comply with all city and county ordinances and stale laws TOTAL: . W ELECTRIC FEE QTY. MECHANICAL PERMIT' FEE PERMIT ISSUANCE PLUMBING FEE _ Q MECHANICAL FEE FEES PAID: .' relating to building construction, and hereby authorize representatives of this city to enter upon the above-mentioned property for Inspection purposes. (We) agree to save, Indemnify an d keep harmless the City of Cu pertlno ALTERORADDTOMECH' Dote ReCei tic 'SUBTOTAL: against liabilities, judgments, costs ami expenses which may in any way accrue y In con.eque ce the granting of this permit, AIR HANDLING UNIT (TO 10,000 CEM) AIR HANDLING UNIT (OVER 10,aa0CFM)• CONSTRUCTION TAX aturc ppllom / ..tactor EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:' HAZARDOUSMATERIALSDISCLO RE HEATING UNIT (TO 100,000 BTU) Will the applicant or future building oav pant store or handle hazardous material as dented by the Cupertino Municipal Code, Chapter 9.1 2, and the Health aand Safety Code Section 25532(a)7 Rture ., Date ,Racal Iq HEATING UNIT (OVER 100," BTU) TOTAL: D VFNDLATION rAN(SINGLE RESID) ISSUANCE DATE . . Will the applicant building ocmp6rt use equipment ordevices which emit In vent....1, roma minant. as de0 red by the Bay Arm Air Qua lily Ma nagement Distria7 4 Yts Q. No have road the of out matedale mons A BOILER -COMP OHP. OR I BLOOD BTU) + flOU.ER-COMP (OVER 100,000 BTU) Health & the Gll(omia Health ASafety Coda Sections 75505, 75533 and 25531.1 255 5, 2553 and2S5Chapter. I understand that lithe building don not mrrently have atenanl, that ltbmy' 12 1991 NEW RESIDENTIAL MSCI i. SQ.FT. us to of the rcqulremenis which must be .ret DEC priort-. c of a Cthe.ccupant prior l_o Wuance o(a Certificate otOmtpanry. - ' Clr��r Ui'trtluv�. ISSUED BY: Owner or authorized agent - Data OFFICE COPY