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24422 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PERMIT N24422 4 4 2 2 Building Address: wn n ame� one. CITY OF CUPERTIN4BUILDWG DIVISION A . cont ors rat D u No APPLICATION /PERMIT ArchitM/Engineer.Rlw� I BLEC 7LDING-ELECTMCALPLUMBINGMHAMCAL CATEGORY CONTROLG+CkbIr. N QTY ELECTRIC PERMIT FEE BUILDING PERMITINFO Address: PERMITISS(IANCE El El CONTRACTOR'S DECLARATION Iherebysffirm that!am licensed under provisions of Chapter 9(ommenc APPLIANCES-RESIDENTIAL JOB DESCRIPTION Inense Is ectlon force and offeon3 olthe Buslnessand ProtemlonaCade,and my license is in i..force and effect. PANELS License Clam LicN Date Contractor LM TO 2DOAhMS / - ARCHITECT'S DECLARATION 201-1000 AMPS �q'+re0 O I understand my plan re BLUE be used as public cords OVER 1000 AMPS p p R S/SQ.FT. M Q U Licensed Professiovl SIGNSELECTRICAL P U T ER 6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC Ihereby affirrnthat lam exempt from the Contractor's License law for the pp following reason.(Section 76715,Business and Professions Code:An city O71't� coon which requires permit rontmd,alter,im Yor TEMP.METER ORPOLEINST. F� county qu pe prove,demolleh,orrepair _ r g atanystruclum prior to its!nuance,ahorequlres theappllcant forsuch permit to O file a signed statement that he is licensed pursuant to the provision of the POWER DEVICES Contractors License Law(Chapmr9(commencingwith SeMion 7000).(Divi- SWIMMING POOL ELECTRIC sion3 of the Buvnesaand ProfesslovCode).rebate helaexempt thore(romand VALUATION y.' the basis for the alleged exemption. Any violation of Section 7031.5 by any �ppapplicant for.perMtBubjects the applicant to a dvil pevltyof na morethan OUTLETSSWHCHESFIXTIIRES _tee c, �c� five hundred dollars(S500). NEW RESIDENTIAL ELFC7R —� O �n r7 1.as owner of the property,or my employees with wages as their sole eSQFT. STORIES TYPE CONSTRUCT ION compensation,will do the work and the structure Is not intended or offered for O role(Sec.70K Business and Profession Code:The Contractors License Law S� doesnmapply to an owvrof propertywho Wildsor improves then.Rand whodeessuchworkhimself orthrough hisownempleyees,providedthat such OCC,GROUP RES.UNITS Improvements are not intended orolfered forsale.If,however,thebullding or TOTAL: improvementbs ldwith!noneycarofcomplet ,theowner- gderwBlhave t rdenotprovingmat he did notbuildorimproveforpurposeofvle.). QTY. PLUMBING PERMIT FEE FLODDZONE APN �I,as owner of the property,am exclusively ontrading with licensed 1'FRMI7155IlANCE contractors to construct the projM(Sec.7094,Business and Profemlom Code: The Contractor's License Law dont one apply to an owner of property who buALTER-DRAIN&VENT-WATER(EA) Wilds or improve thereon, and who contracts for such pi ejects with a �q¢L[ador(s)Ilcenaed punuanttothe Contractor'sLkrnse Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY LJ I am exempt under Sec. B &P C for this reason DRAINS FLOOR ROOF,AREA,COND. SANITARY Y— N OUTSIDE H Owner Date RECEIPT# WORK MAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCI{OOLTAX Y— N ❑I hereby affirm that I have a cert7ficate of consent to pytheure,ora RECEIPT# certificate o(Workers'Compenatlonlnurance oraorti(kd ropythero((Soc. GAS•EA SYSTEM-1 INCA Policy CJ PARK FEE Y N Poliry tl RECENT X C CAS EA.SYSTEM-OVER 4(EA) BUILDING DI V ISION FEES Ified copy is hercbyth the city CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE Certified ropy la filed with the sty Inspmlon divlNon. CERTIFICATE OF EXEMPT ION FROM WORKERS' CREAS'ETRAP PAID COMPENSATION INSURANCE (Thlsu ionneeanMb complee Btheper tLaforovhundreddollars SEVVER-SANITARY-STORM E.A.RIOFT Date Reoel t# (51less.) ImmWATER HEATER W/VENT/ELECTR ENERGYFEE Y N !certify that lathe performance.(the work"which this permit is issued, N— I shall not employ any person in anY manner eo n to become subject to the WATER SYSTEM TR Workers'Compensation laws of California.Date / �n'� PAID O Z Applicant Z O NOTICETOAPPLICANT:If,after making this Certificate of ExempOon,you NEW RESIDENTIAL I7MB. SQ,FT, Date Recei t# Hshould become subject to the Worked Compevatlon provision of the Labor TOT WVI Code,You must forthwith comply with such provision orthis permit shall be a` > seemee revoked, BUILDING FEE CL C CONSTRUCTION LENDING AGENCY !ELECTRIC SM!BING E Ihereby amrmthat them baconstromon lending agency for the perform. TOTAL: FEED Z ance ofthe workfor which this permit is Issued(Sec.3097,Civ.C.)O I<nder§Name MFEELL h Lendera Address QTY. MECHANICAL PERMIT FEE CHAL FEEOW Icertdythatl have read[hisapplicatlon and statethatthe above lnformatlon6 hcormd.l agree to comply with all Mtyand county ordinances and state laws PERMIT ISSUANCE S} relating to building ontmetion,and hereby authorlm representatives at thiocity to enter u Pon the above-mentioned#rope for ivpedion purposes. ALTER OR ADDTO MECH. (We)agree to save,indemnify an d lees rmieas the City of Cuperino DReceipt# againtilabilltl ,lodgments,ones and ex which ma nywayamma AIR HANDLING UNIT(TO IO,ODO CFM) SUBTOTAL, agalnt Bald C In co gapience of t of thio it AIR HANDLING UNIT(OVER IQDOOCFM) CONSTRUCTION TAX Sig core of pplFIA2A RDOUSiont/ConractoMATERIALS DISCLOSURE r Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: ill the plicant ng Wialas Spred b the ertino Municipal Code, hapten lc havardous F{FATINC UNIT(TO 100,000 BTU) Date material as defined by the Cupertino Munidpal Code,Chapter 9.17,and the RCCC QYes11rallhand SrfMy Cod c,Scnoon 25532(a)? HEATING UMT(OVEF(t00,0006TU) •FO ` Will the applicant or❑future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District? BOILER-COMP OHP OR 100,000 BTU) Yes ❑1�No m A have read the hazazQinornnterials requirements under Chapter&95 of BDRER-COMP(OVIR 100,000 BE U) V' W D the Ca lifomW Iiealth&Sa tett'Cade,Sed Ionia 75505,25$33 and 25534.I understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.PT responsibility to rad ify the occupant of the requirements which must be met ' ���� prior to taints s race of a Certificate of Occupancy. Owner or authodzeaagent Date CIIY OF CUrtrl I11vtI TOTAL: ISSUEDBY: OFFICE COPY