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24328 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES _USE BALL POINT PEN ONLY Building Project Identification - - PERMITNO. Bueding Address: 24328 / 0 -C 1 CA V nera ame. hone: p 'TOS67 l4,voi C 733 -6z3 CITY OF CUPERTINOLBUILDING DIVISION s Z . Com red.ra Name: Lie.No: APPLICATION /.PERMIT , Gn "1 S l Z- I 6YO O BUILDINC-ELECTRICAI.PLUMBING-MECHANICAL CATEGORY CONTROL# Architect/Engineer. Lk.No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address - PERMITISSUANCE ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION I hereby affirm that Iam licensed under provisions of Chapter 9(commenc. APPLIANCESRESIDEMMI, )OB DESCRIrl'[ON ing with Sinton 7000)of Dlvfect. ftheBusineaand lProfesslontCode,and my ` Ltenseisinsc and effect. PANELS ID UP TO 200 AjMS ^ License Class�(�L4.# �a N04a)/ �P-Q Dale Contractor/V,yl�ti' 201-1000AMPS ARCHITECTS DECLARATION o lz Iunderstand my plans shall be used as public records..- OVER1000AMPS - SQ.Ff.FLOOR AREA '$/SQ.FT.. Licensed Professional SIGNS ELECTRICAL �, ® ' 6 OWNER-BUILDER DECLARATION I"n 3 SPECIAL CIRCUIT/MLSC �, PUT E Xs, [hereby a((Irtn that[ism exempt(romthe Contradorb Llrense Law for the following reason.(Section 7031.5,Business and Professions Code:Any city or Ft- C TEMP.METER ORPOLE[NBT. � ountywhich require,,permitle core[run,alter,improve,demol4h,orrepair g anystrodom priori.Its aam.n,.4orequlrestheappllcant forsuch perMtto POWERDEVICES t5 O file a signed statement that he is licensed pursuant to the prevalent of the IE lJ Q6 µ Contractor's License Law(Chapter 9(commencing with Section 7000)of DintDN - �0 gon3 ofthe Businessand I'mfessioreCode)mthat he is exempt therefromand SWIMMING IDOL ELECTRIC VALUATION ,the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFIXTURES applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500). E]L as owner of the pmperty,or my employees with wages as their sole NEW RESIDENTIAL ELECTR SQFT, STORIES TYPE CONSTRLCTION compensatlon,willdothe work,and thestmdure 4 entimanded or offered for p sale(Sec.7044,Business and Professions Code:The Contractors License Law $ does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES.UMTS who does suchwork himself orthrough his own employees,provided that such Improvements are not intended oroffered forsale.If,however,thebulldinger TOTAL- Improvement issold OTAL:Improvement,sold withinoneyearofcompletion,the owner-builderwill have tl(9�urden of proving that he did nor build or Improve for purpose of sale.). (TTY. PLUMBING PERMIT FEE_ FLOOD ZONE APN u I,as.caner of the property,am exclusively Contracting with licensed - cemr.cmto cometnact the project(Sec.7654 Business and Professions Code: PERMIT ISSUANCE AA The Contactors License Law does not apply to an owner of property who --- ALTER-DRAIN k VENT-.WATER(ENIrY Wild, or Improves thereon, and who Contacts for such p(ojects with a <q➢tfador(0 licensed pursuant to the Contractor.License Law. FEE SUMMARY L�I am exempt under See. ffl B h P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDEFEES DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N • Owner Date RECEIPT# WORKMAN COMPENSATION DECLARATION affirm FIXTURES-PER TRAP �j QxC SCHOOLTAX Y N_ QI hereby arm that I have•certificate of consent to,elf-insure,or a RECEIPT# cemficate of Works.'Compevrtlonlrourned,or a Certified copy thereof(See. 3800,Lab C3' GAS-GAEA.SYSIEN-11NG4 OUTLETS PARK FEE Y N Policy# GAS EA.SYSTEM-OVER 4(EA) RECEIPT# Co any BUILDING DIVISION FEES MCCAlfied copy a heed with he City CREASE/INDUST'RL WASTE INTERCEPTOR PLANCHECKFEE ffMlfled copy I.flied with the City inspection divlelon. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE7RAP PAID COMPENSATION INSURANCE SEWER-SANrTARY-STORM EA 2001T Date Recei t# (Ih4 sess.) need notbe completed-(the permit 4(or ane hundred dollam ($100)mftifyss.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N [certify thatln the performanceI.any wok f.rwhibecomepermit jectIssued,the N— I ork not employ any person In any manner ao as to become subject to the WATER SYSTEM/TREATING Worker Compensation Laws of California.Date � - PAID ' ZZ Applicant NEW RESIDENTIAL PL.MB. SQ}7. Date Recei t# O NOTICE TO APPLICANT:[,after making this Certificate of Exemption,you should become subject to the Worker Compeaation provisions of the Labor - TOTAL: M Code,you mu at forthwith comply with such provLslore orth4 permit shall be BUILDING E > deemed revoked. III G CONSTRUCTION LENDING AGENCY SEISMIC FEE CL Iherebyaffirm 4 that there 4 a Construction lending agency forthe perform, SQ ELEC'T'RIC FEE Z ance of the workfor which this permit 4sued(Sce.3097,Civ.Q TOTAL: V Q Lender.Name PLUMBING FEE .Q LL F Lender'apddreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE O W IcertBythatl have read th45pp11rallonand state that Nfornutlan IL acorred.I agrerea comply with all city and muntymclina ed,and nate laws PERMIT ISSUANCE FEES PAID: N relating to building Construction,and hereby autho ,a,repreaenlallves of this F Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADDED MECH. Dale Recti t# V — (We)agree to ave,Indemnify an d keep harmless the Cityof Cupertino against habiluies,judgments,.9...d expenses which may in any way accrue AIR HANDLING UNIT(TO I0,"CFM) SUBTOTAL' -Q against said City In consequence of the granting of this permit �jy///-,yea_ uJ AIR I;ANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX Signa/N �fApplic nt/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS) IALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recti f# material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the ^a Health and Safety Code Section 25532(a)I HEATING UNIT(OVER 100,000 BTU) TOTAL: / �0 r-1Yea ,La_�,No Will theappilant orfuture building ocapantmeequipment mdevice, VENTLATTON FAN(SINGLE RESID) ISSUANCE DATE which emit hateardous air contaminants as defined by the Bay Area Air • Qu lily Management D4Md7 BOILER-COMP QHPOR 100,000 BTU) y� ik Pi f D ❑Yes MTL�1I No r [have read the haza Tous materials requirements underChapter6,95 of BOILER-COMP(OVER 100,000 BTU) the California Health k Safety Code,Section 25505,25533 and 25534.1 12 1992 understand that if the building does not currently have a tenant,that It a my NEWRESIDFNTIALMECH.- $Q.FI. OCT (� �7G responsibility to notify the occupant of the requirements which must be met prior 1.Issuance of a Certificate of Occupancy. ' )+{T1111VV X11 Y yr l 5 Owner or authorized agent - Date - ISSUED BY: TOTAL:' OFFICE COPY