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23861 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PERMIT NO. BvOd"Aa s neo De . 23861 J5 5era ante n5e. CITY OFP CUPERTINO-BUILDING IPER DIVISION ��/) Conmactor'e Name: 6 .a/ Lie.No: 1. N vLUrU.I(JI/V 1�� .BUfLDINGELECTMCAL-PLUMBING-MF HAMCAL CATEGORY CONTROL N ArcAaect/Engineer. Lk.Na: - QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Addiesa: POWTIS5UANCE ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION lbereadionmlhallamBcen3oftheunder provkdonaof Chapler9dco, med APIPIIANCE6RESIDENTAL JOB DFSC ON Ingwlth Seanun 70. ap'effeon3oftheguslwsand PmlesalonsCode,and my , I I icense is In fu ( an dlM. rrl PANELS Lirense la Lk.M ✓JC Data — Contractor trF NIH ARCHITECT'S DECLARATION 201-1000 AMPS N 7O I uMerstand my plans shall be used as public records. OVER 1000 AMPS SQ.Fr.FLOOR AREA $/SQ.Fr. Fe Licensed Pmfemlonal SIGNS ELECTRICAL <<�Q OWNER-BUILDER DECLARATION SPECIALCIIiCU1T MLSC LA IherebyafRrrothat l am exempt firm the Contractor's License law for the / I E D I B qqq following reason.(Section 70315,Business and Pm(easlons Code:Any city or county which requires a permB to constrot,alter,improve,demolish,or repair TENP.METE40RPOLEINST. g� Q any stroctum prior to its issuance,also requires the applietutfonuch perMtm L9'rVE U file a signed statement that he Is licensed pursuant to the provisions of the POWER DEVICES f Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi-. SWIMMING POOL ELECTRIC p sian3oflhe BuNnemand Professloru Code)orthatheheaempttherefmmand y the basis for the alleged exemption. Any violation of Section 70)15 by any <$ apph..tI..permit subjects theapplie.rd too civil penalty of not more than OUTLETSSWITCHESFIXTURES five hundred dollars($SM. NEW RESIDENTIAL ELECTR 7< ❑I,as owner of the property,or my employees with wages as their sole �'�' OW ES TYPE CONSTRUCTION compensation,will do the work,and the structure Is noInte t nded or offered for O sale(Sec.7044,Business and Profemlons Code:The Contractor's License law I2j $ does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RIS.UNITS CC: whodoee such work hlmselforthrough hisownemployees,provided that such Improvement am not Intended oroffered forsale.If,however,thebulldingor TOTAL: impmvement bwld wtthinoneyearofcompl&loM1theowner-bullderwill have th,kurdenof proving that he did not bund orlmprove for purposeofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE ArN LI L as owner of the property,am exclusively contracting with Iirenxd contractors to conalmct the project(Sec.7044,Business and Professions Code: PERMIT ISSUANCE l The Contractor's 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 pw*M with a ofpllanor(s)licensed pursuant to the Contmetols License Law. FEE SUMMARY Ll l am exempt under Sec B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES .at DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N Date RECEIPT M J WORKMAN COMPENSATION DECLARATION pIXTURES PER TRAP SCHOOL TAX Y N hereby affirm that I have o mridleInsurance of consent to pythemof ora RECEIPT M certRlcateo(Worken'Compevatlon lneurena on certified ropythemof(Sec. GAS EA.SYSTEM-1 INC.4 OUTLETS 350q Tab CJ 'J/J PARK FEE Y— N_ Pol a Io?9�3.�JD'� � RECEBTp Caman C1 Tom') GAS EA.SYSTEM-OVER4(EA) Y BUILDING DIVISION FRCS __C�ed copy is herebyfurnished.the city CREASE/WDUSML WASTE INTERCEPTOR PLANCHECK FEE rtiBed ropy t Ned with!be city Inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID COMPENSATION INSURANCE SANTTARY- (Thlssection need not becompleled lfthe permit lsforonehundred dollars SEWER- STORM EA.200FT. Date Receipt# ($1I a,fifess.) WATER HEATER W/VENT/E.ECTR ENERGY FEE Y N Illnot thatoto the persemiaoftmanner so as tobthis permitct Is to theed, — I shall not employ any person in any manner w as ro become subject to the ' Workers'Compcnsalon laws WATERSYSI.EM/TREATING o/Callfomla.Date PAID O Z Applicant Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLM& SQ.FT. Date RCcel t# Hshould become subject to the Workers'Compensation provision.of the Labor TOTAL: CC W Code,you moat forthwith comply with such provisions or this permit shall be > deemed revoked. B IL I W a — CONSTRUCTION LENDING AGENCY SEISMIC FEE _ IhxmbyafIthat there la a corutmctlon lending agency forthe perform ELEC'T'RIC FEE M Z once ofthe workfor which this permit b Bound(Sec.3097,Civ.C.) TOTAL: 00 lender.Name PLUMBING FEE u. IendereAddress QTY. MECHANICAL PERMIT AEE MECHANICAL FEE WIcertl/ylhatl have read thisappllcationand statethatthe above information 1 Isomect.Ixgree to complywith all etyand county ordinances and state laws PERMIT ISSUANCE FEE$PAID: W relating tobullding construction,and hereby authorize rcpresentatives ofthb H Z city to enterupon the above-mentioned property for Inspection purposes. ALTER OR ADDTO MECH. Date Recei t# _ (We)agree to save,Indemnify an d keep no p harmless the City of Cuperti agalnsthabi judgments,ceemaut ex sesw Ichmay In anywa accrue AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL: against enre of the tl t milt. ATRHANDLING UNIT(OVER10,000C III CONSTRUCTION TAX s f A Ir nye c nr a!e E7(FAUSTHOOD lw/DUCT) CONSTRUCTION TAX PAID NA2A US MATERIALS DISCLOSURE Will theappllant o rebuilding occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date ReCel t# materialasdeflnedby. Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Cade Section 25532(e)7 HEATING UNIT(OVER 100,00)BTU) TOTAL- s ❑YrsN No Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISS %N+CEr DATE which a Mame ant iircontaminant as defined by the Day Area Alr, AID V Quality ut hamr ou m❑sec t BOILER-COMP OPIPOft 100,000 BTU) 4 Yea N No have read the haze ousmaterials requirements underChapter 6.95 of BOILFR-COMP(OVER 100,DDD BTU) JUN 00 the Callfemla Health&Safety Code,Sections 25505,75533 and 25534. 1 UN V 1992 understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQFr responsibility Isla c of ify aCeheocte of oftherequirementa which most be met CII Y 4r t,urr prior to Issuance o/a Certificate o(Occvpamy. � 4_ TIIII Owner or authonad agent Data TOTAL: 1SSUEDO _ OFFICE COPY