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23909 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Hultding Project Identification PERMIT NO. Building Addreao 23909 22 a PIFN.erl Q neve came: one: p . CITY OF CUPERTINO�BUILDING DIVISION contractor,Na Lic.No: APPLICATION I PERMIT (s —jj�•-� BUILDING-ELECnUCALMUMBINC-MECHAMCAL CATEGORY CONTRCt?6I Amhite t/Fngfneer. Lk.No: (��1. ` QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO Address: PERMITISSUANCE I � ❑ ❑ LICENSED CONTRACTOR'S DECLARATION I hereby afirrnthat l am licensed under provisions of Chapter 9(mmmenc APPLIANCESRRSIDENTIAL OB DESCRB'RON Ingwith is ien allionorforce )of an effect fectMo fthe Busess nand ProfessionsCode,end my license d e PANELS License Class Lie.N Date Contractor UP TO 2DO AMPS ARCHITECPS DECLARATION X11-1000AMI5 quq�au K ZO I understand my plansshall be used as public records OVER 1000 AMPS SQ.PT.FLOOR AREA $/SQL.FT. Fi Z 0 Licensed Professional SIGNSELECTRICAL S� <Q OWNER-BUILDER DECLARATION O O SPECIAL CIItCUfT/MLSC f., Ihercby affirm that lam exempt from the Contractorb License law for the following reason.(Section 7031.5,Business and Pro(essbns Code:Any city or TQdp MEFER OR POLE!NSP. county which requires a permit to construct,alter,improve,demolish,or repair Cal anystmcture prior to its Issuance,also requires the applicant for such permit to POWERDEVICFS c 5 ilk a signed statement that he Is licensed pursuant to the provisions of the Contractors License (ChapterLaw 9(commencin with Section 700D)ofDivi-30C' sm.3oRhe Businessand ProfeionsCode)orthatt hebexempttherefromand SWIMMING IT OLE ECRC VALUATION 5 the basisfor the alleged exemption. Any violation of Section 7031.5 by any U OUTLETSSWITCHESFIXTURESsaa applicant fare permit subjects the applicant to a civil penalty of not mare Ilan , RI �s p, five hundred dollars($500). NEW RESIDENTIAL ELECTR EQ.FT, STORIES TYPECONSTRUCTTON �n as owner of the property,or my employees with wages as their sole co pensa0on,wllido the work and thestmcture b not intended or offered for nas e(Sec.7044,Business and Professions Code:The Contractors License Law t?jQ does not apply to an owner of property who builds or Improves thereon,and OCC.CROUP RFS.UNITS E who doessuchworkhirnselforthraugh hisown employees,provided that such Improvements are not intended oroffered forsele.If,howeveq theWilding or T Improvement issold wdhinoneyearofcompinlon,the owner-bullderwill have the rdenof provmgthm he did rot wild mimprove for purposedsais.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN L°L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE contractors to construct the project(Sec.7044,Business and Professions Code: The Contractors License Law does not apply to an owner of property who ALTER-ORA W kVENT-WATER(EA) wilds or Improves thereon, and who contracts for such projects with a FEE SUMMARY ,,11BBfIactor(,)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE LJ I am exempt under Sec. B 6 P C for this reason 'FEES DRAINS-FLOOR,ROOF,ARECOND. SANITARY Y N Owner Date A, RECEIPT N WORKMAN COMPENSATION DECLARATION F-11rm FIXTURES PER TRA!' SCI400L TAX Y N 1 hereby affithat I have•certl0ate of consent to self-Insure,or RECEIPT N certificate ofWorkeri Compereution Insurance me certified mpythereof(Sec. GAS FA.SYSTEM-1 WC4OTTLETS PARK FEE Y N 3800,lab C.) — RECEIPT N I'olkyN CAS EA.SYSTEM-OVER 4(EA) BUILDING DI VISI FEES Com raCey nified copy b hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE rj Certified copy b filed with the city inspection division. L a CERTIFICATE OF EXEMPTION FROM WORKERS GREASETRAP PAID COMPENSATION INSURANCE SEWER.SANITARY-STORM EA.200FT. Date e<:el t# (This section need not be completed lithe permit is(or one hundred dollars ($100)0rloas) WATER HEATER W/VEM/ ENERGYFCE Y N- 1 cemfythat in the performance of the work for which this permit Is issued, I shall not employ any person in any manner so as to become subject to the WATQt SYSTEM/ Workers'Compensation laws of California, Date PAID 02 Applicant .pr, �. Remi t# Zmaking O NOTICE TO APPLICANT.I(,after this Certificate of Exemption,you shmld become subject to the Worker,'Compematlon provblov ofthe tawr TOTAL. N Codgyournu,Iforthwith comply wlthsach provisions orthla pemdtshall be s B IL G W j deemea revakea. CONSTRUCTION LENDING AGENCY S ISM FEE d Z I hereby affirm orkforthat whit the.b a con it is in n ld(Sec. 097,Cie. pertorm TOTAL: EL RIG 1'E• 02 arm Lender Nwork(orwhkhthbperntblasued(Sec.3097,CIv.C.) PLUMBING FEV - LL lenders Names LL N Lender,Addmss QTY. MECHANICAL PERMIT FEE MECHANICA FEE 0 W 1odifythatl have readthisapplicationan statethattheabove information 1 becreect.l agree to comply with all cityand county ordinances and sate laws PERMIT ISSUANCE FEES PAID: } relating to building construction,and hereby authorize representatives.(this F N city to enterupon theabove-mentioned property for Inspection purposes. ALTERORADDTOMECH. V Z (We)agree to save,Inde n d keep harness the City of Cupeniro Date Receipt# against Ila IBn,N and expenses which may many yacaue AIR HANDLING UNIT(f010,UK)CFM) BTOTAL: againa eceoft an hlspe nCO AIR HANDLING UNIT(OVER 10,MOCFM) CONSTRUCTIOrkTAX Weq.1preemcudevices of v t ontractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: NA USMATERIALSDISCSUsupplicant to ulldingescvpantst or ndlehavardous HEATINCUMT(TO10BODOBTU) Date of t#sciefined t Cups mM.nldpal CodaCh c,9AZa.dthe 4d Saf nion 32(1)7HEATING OMT(OVER 100,000 BTU T (t�.Noe cap �m car lutum buildi occupant equlpreemcudevices VENTILATION FAN(SINGLE RESID) ISSUANCE ATE t ousalrmntannanaa by the Bay Area Air aragemcnt Distrin7 BOILER-COMPPIIPOR100,000BTLnp nn No P A 8 D madthehuam�ousmaterialsrequirementsunder Chapter 6.95of BOILER -COMP OVR103,0008TU) the California Health 4c Safety Code,Sections 25505,75533 and 25534. 1 understand that if the building docs not currently have a tenant,that it is my NEW RESIDENTIAL MECii. SQ.PI JUL responsibility to notify the occupant of the requirements which must be met an prior to issuance of a Certificate of Om pa ncy. a Owner or authorized agent Date ISSUED it TOTAL: MVV VM r TOTAL: OFFICE COPY