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24429 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY Building Prom lderkifioeon 7 PERMIT N B°Rdleg Addna.: O. 24429 D2_64 0,0 Ave- er• ame: Phone: A zS3'6' Z CITYOFCUPERTINO�BUILDING DIVISION • Con Ptraaor's;ame: 1f APPLICATION / PERMIT l Til / BUILDINC-ELECTRICALPLUMBING.MECHANICAL CATEGORY GONTROLN Architect/Engineer. Lk No: t QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO Address: D Z /1 ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION I hereby afilrm that l am licensed under provisions of Chapter9(commene APPLIANCES-RESIDENTIAL JOB DESCRIPTION Ingwith Sealon7000)of DivWon3ofthe Budwsand ProfeWonsCode,and m license is In full to deffM. t PANELS Llrenm C6m LiaM L(%%01 Date 11—i—aI LComraaor'��I ARCHITECP EC TION 201-I WO AMPS ev Iundemland my plansehalf be used mpublfcrecoNs. OVER1000AMPS I S/SQ.FF. ��❑❑uu CO E (� Licensed Profememl SIGNS ELECTRICAL ! i�4J �� n n cid 6 LN OWNER-BUILDER DECLARATION SI'DCIALCIRCUIT/M19C 'NIJtl ZI., mviageson.Ehatlamexemp( .dd.ContmaI. LCd.:Awtorthe pp following recon.(Seaton 7031.5,Budnem and Pimprove, Code:h o city lr O2, � TEMP. OR POLE INSf. K� aeuntycture prguinna r1.R.Iemktocomtroairesthapmvgt forsueh,ormitt116 g any atruaurc statement that he olive sed pursuant t the formions of It a ppSygR DEVICES file a signed katemen[that he V licensed pursuant to the provisions of the Q63µ Contractor's License Law(Chapter 9(comoencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION SOS kon3ofthe Budnemand Pre(emlo.Code)artheheidemmpttherefromand O the Dais for the alleged exemption. Any vloladon of Section 7m15 by any O[TILETSSWITCFNSFIK'fURES applicant fora permit subjects the applicant to a av11 penalty of not morethan $ five hundred dollars($500). NEW RESIDENTIAL ELECTR ❑I,as owner of the property,or my employees with wages as their sale �' STORIES T TE CONS RUCTION compensation,will do the work and the structure isnot intended or offered for paxle(Sec.7044,Business and Pmfemloru Code:The Contractor's License law 3$ docs not apply to an owner of property who Wilds or Improves thereon,and OCC.GROUP RFS UMTS whodonsuchworkhlmself orthmagh hisownemployces,provided that such Improvements are not intended oroffered forsale.If,however,thebuildingor TOTAL Improvement bsold Mthlnoneyearofcomp101.,thuowner.W BderwRl have dl,,kurden of proving that he did not build or lanprove for purpose ofmle.). QTY. PLUMBING PERMIT FEE J FLOOD ZONE APN L [as owner of he property,am exclusively Business andcontractingPro with licensed PERMIT ISSUANCE contractors to construct the projeet(Sec.7816,Business and Professions Cade. () The Contractor's Licence Law does not apply to an owner of property who ALTER-DRAIN kVENT-WATER(FA) Wilds or Improve.thereon,and who contracts for such ptojects with a FEE SUMMARY ��Iffaaor(a)licensed pursuant to the Contractors License Law. IN am exempt under Sem B A P C for this region BACK FLOW PROTECT.DEVICE rurrgirlF DRAINS FLODR ROOF,AREA,COND. SANITARY Y_ N_P • Owner Date RECEIPTWORgNAN COMPENSATION DECLARATION 01 SCHOOLTAK Y N ❑1 hereby affirm that I have a certificate of consent to self-Indue,or• FIX,IlIRES PER TRAP RECENT N cenlflrate of Workers'Compensce ation Insurance or a certified copy thereof(Rec. CAS EA. IA-1 INC.40[ITLECS PARK FEE Y N Polis M lib C3 RECEIVE If Policy GAS EA.SYSTEM-OVER 4(FA) Co��m aa��ray BUILDING DIVISION FEES 2Cediled copy is herebyth the city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE Certified copy Is filedhere with the sty inspection diWelon. CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWER.SANITARY-SIDRM F.A.7007f Date RiNCl tN (This auction need not be completed If the permit asfar one hundred dollars (510(fiarlem.) WATER HEATER W/VENT/ELECfR ENERGY FEE Y N I amity that In the performance of thework forwhlch this permit is issued, I shelf nm employ any person in any manner so as to become subject to the WATER SYS.I.QA/.IRFA.DNC (�O PAID - 0 tlonlawaof Gllfomia.Date O Z Applicant NEW RESIDENTIAL LMB. SQ}7. Date Reoei til Z O NOTICE TO APPLICANT.If,after making this Certoflfiale Exempten,you should becomesubject to the Wmlk ns'Compermtioa providers ofthe Labor TOTAL: aq Code,you=at forthwith comply with such provisions orthls permit shall be BU ILDING FEE W > deemed revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE a Z Iherebyaffirm that there b a construction leadingage.ey for the perform TOTAL Qd ELECTRIC FEE anwoftheworkforwMchth6per ti. me (See3097,CIv.CJ 02 lander.N. PLUMBING FEE D U. F= Lender's Addr, QTY. MECHANICAL PERMIT FEE MECHANICAL FEE Omrtifythatl have readthis appllcatlon and state thattheabovelnformatlon a iscorrea.I agreeto comply with all city and county ordinances and kale laws PERMIT ISSUANCE FEES PAID: >- W relating to building construction,and hereby authorize representatives of th'a - H U) city to enter upon the above-menteneci property for Inspection purposes. ALTER OR ADD TO MECH. Date Recei tN (We)agree to save,Indemnify an d keep harmless the City of Cu pent.. V against Babilltku,jsdgmcros,code and expenses which may In any way accrue AIR HANDLING UNIT ITO 10,000 CFM) SUBTOTAL' aga but mid City In an eseeoft .gra gof this permit. �� m �,� ;� AIR HANDLING UNIT(OVERIO,000CFM) CONSTRUCTION TAX SI tore of ppllcant/Contractor to EXHAUST 110013(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous HEATING UNIT CID 100,ODO BTU) Date Recei tN material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the Health and Safety Cod rt Code eSSecion75532(s)7 HEATING UNIT(OVER 100,00D BTU) TOTAL: s� RY. ill he applicant orfuture building occupant use equipment ordevicn VFN'17LATION FAN 61NGLE REMO) ISSUANCE DATE which emit hazardous ab contaminants as defined by the Bay Arca Air Quality Management District? BOILER-COMP OFN OR 100,010 BTU) r� Al 0 Yes ❑ 4ha .read the hazardoNo us materials requirement,under Chapter 6.95 of BOILER-COMP(OVER IW,DOO BTU) the Celifomla Health&Safety Code,Sections 25505,75533 and 75534. I Nov' , 1[1[19 undertand that don not the building donet h currently have a tenant,that it my NEW RESIDENTIAL MECH. Ff VV .PJM SQ responsibility to natily the occupant of the requirements which must be met - priortolmuanceof a Certificate of Occupancy. Cur 17CUrtntfi4tad Owner or authorized agent - Data ISSUED BY: `A UCC TOTAL: OFFICE COPY