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23881 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY Building Project Identification -PERMIT NO. Building Address: 23881 •f sera erre: one: C L,I CITY OF CUPERTINO-BUILDING DIVISION conlracinis Nama: S Lk.N9: APPLICATION I PERMIT 7'R BUILDINGELFCTWCALPLUMBING-MECHAMCAL CATEGORY CONTROLN • Amhlten/En n �— Lie.No: - QTY ELECTRIC PERMTT FEE BUILDING PERMIT INFO Address PERAIITISSUANCE LICENSEDCONTRACTOR'S DECLARATION . t—a� I hereby affirm that l am licensed under provisions of Chapter9(exmenam APPLIANCFSRESTDENFIAL JOB DESCRIPTION Ingwllh5I f 117000)u(DiWfect. (the Buslvuand Pro/eeslaneCode,and my a xs.•u erg C' I icense Is In fl1f and effect.N C�-rx PANEIS L `(/�<vF♦r/a, License V Llc p V Date Contractor �L" UP TO 2DO A ARCHITE URA 1 N 701-IOW AMPS reO Zp to Brits mypbvehaB upubBcmcorde. OVERIOWAMPS SQ.FF.FLOOR AREA S/`SQ.FL Licensed Professional SIGNS ELECTRICAL «< OWNER- DER DECLARATION {n SI'EC7AL CIRCUIT/M15C owing axon.(Sullamexempt fromil and orsLicen law forthe following which req unstop permit to7031S,Business and Professions Code:Any city it O F�y9 TEMP.METER OR POLE INST. �� � county requbesapernitto rovtroci,niter,improve,demolish,S any structure prior to its issuance,also requires the applicant for such permit to POWER DEVICES RJ V Ne a signed statement that he is licensed pursuant to the provisions of the FQj 3µ Contractor's Lkeve law IChipler 9(mmmendng with Sedlon 7000)of Divl- �OS ;ion3ofthe Bustnessand ProfesslovCode)mthat he b exempt therefromand SWIMMING POOL ELECTING /A VALUATIgN.- Q the basis for the alleged exemption. Any violation of Sock 70715 by any UILETSSWITCHESFIXTURES !� O/lIa (a(� applicant for a permit subjects the applkantto a civil penalty of not rrore than l9 v�C..11s five hundred dollen(5500). L cue ower of me property, NEW RESIDENTIAL ELECTR Ft. �n ❑ p perry,or my employees with wages as their sok STORIES TYPE CONSTRUCTION rompennation,willdolhe work andthe structure Is not Intended or offered for C O sale(Sec 70K Business and Professions Code:The Contraaor's License Lw $ does not apply to an owner ofproperty who builds or improves thereon,and ^ who does suchwork himself I through his own employees,provided that such OCC.GROIIP RFS.UMTS Improvements are not Intended or offered for sale.If,however,the building or Improvement hsold within oneyearofcomplelbn,the owner-builderwill have tbiLli+rdenofproving that he did am build or improve for purposeofsale.). QTY. PLUMBING PERMIT FEE L j L as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN contractors to construct the projet(Sm 706/,Business ami Notation.Code: PERMIT ISSUANCE �• The Contraciai s License Lw does not apply to an owner of property who ALTER-DRAIN&VFM- bu0ds or Improves thereos,and who contracts fee such ptojecu with a WAS(EW C�p([mtor(s)Emitted pursuant to the Contractor's Licenss Law, BACK FLOW PROTECT.DEVICE FEE SUMMARY LJ I am exempt under Sec B k P C for this reason • Owner - Date DRAINS fl.ODR ROOF,AREA,GOND. SANITARY Y_ N—_ WORINIAN COMPENSATION DECLARATION RECERPf ❑[here SOBOOL TAX Y N M by affirm that I have a msmtiBcate of consent to self-Insure,or a F1XTTlRES PER TRAP certificate of Workers'Compevatlonlvuraner ora cerdard copythercuf(Sec: RECEIPT N 3800,Lab C.) 1 ( CAS EA SY 1 PARKFEE Y— N Policy N o RECEIPT N Cooany GAS U•$1' a r^ .BUILDING DI VISION FIGS Codified copy is hereby furnished. GREASE/w L iDRj PLANCHECK FEE C] ed copy b filed with the city Inspection division. CERTIFICATE OF EKEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SEINER-SA P Date Recei tW eed (this section nnot be completed If the permit Is fora.hundred dolls - alMorleea') WATER HEATER w/VENT/ELEC7R ENERGY FEE Y N I certify that In the performance of the work for which this permit Is luded, — I shall not employ any person in any manner em as to become subject to the WATER SYSTEM/TREATING Workem'Compersatlon laws of California.Date ER PAID O Z Applicant NEW RESIDENTIAL PLMB. SQFF. Date Recef tq Z NOTICE TO APPLICANT:III nuking this Certificate of Exemption,you should become subject to the Workers'Compensation pro,blons ofthe Labor - TOTAL: N Code,you=at forthwith comply with such provisions or this permit shall be ' W Gems derevoked. BUILDING CL CONSTRUCTION LENDING AGENCY SEISMIC FEE 1 herebyaf(Irmthatthere b a rovWRlon lending egcruy for tM perform ELECTRIC FEE D Z an¢ufthe workforwhlch this permit b lssud(Sm.3097,CIv.C.) �� Leefa Name LL d 1= Lender.Addreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE U Icedl"atlhavereadthbapphUtbnandmtethaitheabovelnformatlon O W Iscorren.I agreeto comply with all city and muntyordinancesand elate lawsPFRMRISSUANCE •� FEES PAID: } 1 relating to building mnatruaton,and herebyauthorUa ropresentmivesofthb H N city to enter upon the abovo�meniloned property for Inspection purposes.. ALTER OR ADD TO MECH. ? (We)agree to save,Indemnify an it keep harmless the City of Cu pedino Date Receipt# V against lhbWUcs,jidgments,mets and expenses which may In anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) ' SUBTOTAL: net uld City in consequence of the granting of this permit. AIR HANDLING UNIT(OVER Io,=CFM) CONSTRUCTION TAX signet co ApplIcanl/Contractor Data EXHAUST HOOD(W/DUCT) ,� CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE _ WllltheappBv rat or future building occupantsram ore or handle hadous HEATING UNIT(TO 100,000 BTU) material a a defined by the Cupertino Municipal Code,Chapter 9.l;and the Date Recei Health and Safety Code Section 75532(a)7 HEATING UNIT(OVER 100,000 BTU) TO 5 ❑Yes No Will the applicant or tore building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE which emit haardous air contaminants as cleared by the Bay Area Air p Quality Management District? BOILER-COMP OHP OR 100,000 BTU) _ ' D [?Yes ❑❑No WW have read the hazardous materials requirements under Chapter6.95 of BOTLER-COMP(OVER IDg000 BTU) the California health k Safety Code,Sections 75505,75533 and 25536.I p' 2 2, 1992 understand that lithe building does not currently a have a tenant,that It b my NEW RESIDENTIAL MECH. .FI' responsibilitySQ •��1� ponsibility to notify the occupant of the regWmments which must be met �V prior to issuance of a Certificate of Occupancy. u " Owner or authorized agent Data ISSUED BY: OFFICE COPY