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24117 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project IdentiMkatlan PEILMIT NO. Balt20 24117 wnera one: APPLICA11UN bUb.MLl IAL UAII, I__'1:rV%,Vj0e-9 CITY OF CUPERTINO-BUILDING DIVISION Contractor's Name: Lk.No: APPLICATION /PERMIT ( C (I /V LLL �ES/ BUfLDINGELECTRICA4ML SING-MECHAMCAL CATEGORY CONTROL N Archited/Engineer. Lk.No: QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO Address: PERMITISSUAN'CE ❑ ❑ � ❑ LICENSED CONTRACTOR'S DECLARATION IhthScct(fbmthat fDJviom3 oftheerpessand ofGapkr9(commmc APPLIANCES-RESIDENTIAL JOB DFSCRIPDON inense I,i n all force and o(the Bminevand Pro(esslonsGode,and rtry 1 license k In hg farce and d(ea. PANELS ♦{/1.,a License Class Lic.p PG�wa,lr Date Contractor ARCHITEC1`5 DECLARATION 201-IODOAMPS +q�+Q CO I understand my plans shall be used as public records. OVERIOWAMPS SQ.Ff.FLOO AREA $/SQ.Ff. jou U U Licensed Professional SIGNS ELECTRICAL ¢< OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC a II A� fs . 7 (hereby affirm that l am exempt fromthe Contractors License law for the I" IIYiI\VI 7o 'a fo0owing reason.(Section 7BML5,guslness and Pro(eselone Code:Any ctty or ' O Zp�r TEMP.METIER OR POLE INST. c.ystm=nreortoiape amemmmqui sthenpliuntfrsuchper tto r— ,,��V any assigned statement that he is licca sed pursuant t the provisions of t e L v LI ILL�� ©V file a signed tlatement that he b licensed pursuant to the provisions of the (OWER DEVICES t Contractor's License Law(Cha er 9(commencing with Section 7000)of Divi- 3kin In gw SWIMMING POOL ELECTRIC N sion3ofthelluslaessand ProfessionaCode)orthat hebexempttherefromandJA `u3 6 5 the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWITCHESFlXrURES �O applicant for a permit subjects the applicant to a dvil penalty of not more than five hundred dollars($500). NEW RESIDENTIAL ELECTR �j ❑I,as owner of the property,or my employees with wage as their wk �'�' STORIES TYPE CONSTRUCTION C/¢ compensation,wlllciothe work and the structure is not intended or offeredfor � f] sale(Sec.7014,Business and Professions Code:The Contractor's License Law S$ does not apply to an owner of property who Ito ilda or improves Iherron,and OCC.CROUP RES.UNITS who doessuch work himself orthrough Ms own employees,provided that such ImpmvemenU are not intended oraffered fw sale.If,however,thebuilding or TOTAL: Improvement bsold within oneyearofcompletlon,the owner-bullderwlll have tltjurden of proving that he did not baud or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLCOD7ANE . APN "1,as..of of the property,am exclusively contracting with licensed PFRAMR ISSUANCE contactors to construct the project(Sec.7044,Business and Professums Code: ��Off The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) builds or Improves thereon,and who contracts for such plajects with a FEE SUMMARY Aactor(s)licensed Pursuant to the Contractor's License Law. BACK FLAW PROTECT.DEVICE LJ f am exempt under Sec 0 &P C for this reasonOUTSIDE FEES DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N • Owner Date RECEIPT- WORK MAN COMPENSATION DECLARATION +� FIXTURES—PER TRAP fOv SCIM/X)L TAX Y N ❑I hereby a(((rm that I have a cemfiate of consent to uI-Insure,ora 3 RECEIPT N certificate of W.Ams'Comperwtionlnsurance or a certified oopythereof(Sce. GAS EA.SYSTFM-1 WC.<OUILETS PARK FEE Y N 3800 ,lab C.) (I05 q 7L-� — RECEIPT# Pollcyg U l GAS FA.SYSI'FM-0VER4(EA) Cam any C %'W-Tm 6 Ixf fdei. BUILDING DIVISION FEES Cmined copy is hereby furnished. GRFASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE etlified copy Is filed with the city Inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SE}ypg SAMTARYSTORM EA 2(IOFT Date RecC 11Y (ThissMion need not be completed lithe pemNt k forone hundred dollars ($tOWOrless.) WATER HEATER w/VFM/ELFCTR ENERGY FEE Y_ N_ 1 comifythat in the performance of the work for wldch this permit Is issued, I shall not employ any person In any manner w as to become subject to the WATFIt SYSIFM/TRGT[IvG worinans Compensation Taws of California. Date PAID O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date RST!EL Z O NOTICE TO APPLICANT:ILaIter making thisComfiate of Exemption,you N should become subject to the Workers'Compensation provisions ofthe Labor TOTAL: Code,you must forthwith comply with such provisions orthls permit shall be BUILDING FEE W _ deemed revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE tl Z I hereby affirm that there is a comtmcdon lending agency for the perform- TOTAL: �0 ELECTRIC FEE mon of the work for which this permut b bsued(Sec.3097,Civ.C.) PLUMBING FEE , J V 2 Lender's Name LLF- Lender's Addreas QTY. MECHANICAL PERMIT FEE MECHANICALFEE W l cedifythat l have read this application and gate thaltheabove information O CL mcormct.l agmatoccmplywithalleityand county ordlnancesand gate laws PERMIT ISSUANCE FEES PAID: >. N relating lobuilding ronstmnlon,and hereby awhorlu resentativa o(tM1b r Z city to enter upon the above-mentioned property for ion purposes. ALTER OR ADD TO MECH. Date ReceiptN (We)agrees ave,Inde Asiffy an d keep bar the City of Cupertino AIRHANDUNG UMT(TOl0,0DOCFM) SUBTOTAL' -d V agaWtllabilltka,pdgme ,mgsand pense Ich In anywayaccrue against said City i co ence of gran of tht mut. D CONSTRUCTION TAX �� 2 AIR HANDLING UNR(OVER to,"CIM) Signatumof Applicant/Co ad Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZAR OUS MATERIALS DISCLOSURE Will theapplicant or future building occupant store or handlehaaardous HEATING UMT(TO 100,ODO BTU) material as dfined by the Cupertino Municipal Code,Chapter 9.12 and the Date Recei tp q Health and Safety Code Section 255311a)I HEATING UNIT(OVER IW,"BTU) TOTAL: J-0 ❑Yes M No Will the applicant orfuwm building occupant useequipment or devices VEN711LATION IAN(SINGLE RESID) ISSUANPB DLATE which emelt harardom air contaminams as defined by the Bay Area Air Quality Management District? BOILER.COMP(3FI'pit 100,0411)BM �1 Yrs Q No • `f'havcrcadthe hazar`IiousmateriabrcquirementsunderChapter6.95of BOILER-COMP(OVER 100,00f)BTU) AUG 17 1992 the California Health&Safety Code,Sort Ions 25505,25533 and 25534.I understand that lithe building does net currently have a tenant,that It is my NEW RESIDENTIAL MUCH. SQ.Ff ^ rspneft,ility,to notify the occupant of the requirements which must be met VI11 V4, ysTCr1III1V priorto LauanceofaaftifiateofO¢ pancy. Owner or authonand agent Date TOTAL: ISSUED BY: OFFICE COPY