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24279 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Pmien Identification PERMIT s' NO BnllLing Address: er >a 24279 A7n ners P52^ CITY OF.CUPERTINO-BUILDING DIVISION C trad '�Y.mr:r� S APPLICATION I PERMIT 11, BUILDINGLIECTRICAL-PLUMBINGMECHAMCAL CATEGORY CONTROL N Arcbiled/Engineer: Lk.No: QTY ELECTRICPERM/T FEE BUILDING PERMIT INFO neaha> PERMITISSUANCE ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION Iheh-%dio IrmthatlaiAMon3ofthe erjrrovbloneof C'h on,C deo do APPL[ANCESRESIDEN77AL JOB DESCRfiTION Been hSedbn71700)of Dlvidon3ofthe Budwsand Pro(esslom Code,and my - © /s i Been 1,In fuB and d(ed. /C.� PANES d" �rC3 �ja'Y License Class Lk.N �� `n �- Date Contrador T plans hall be aCLARAT N OVEROOAMI"3 IXO ZO I understand my p6ru shall be used a public records OVER]000 AMPS SQ.FT.FLOOR AREA 5/SQ.FT. ly Licensed Professional SIGNSELECTRICAL /- OWNER-BUILDER DECLARATION L p^E ® IN \ In SPECIALCIRCUIT/MISC ffff.--... 1 r ,., owing reason. that lam31.5,Business from the sad Peoldole Llmmv Lw fmthe ZO following reason. ea p 70X.5,Business and Pro prove, Code:My sty it 1"`� N� t.� TEMP.METFROR POLE INST. �` ,K\ muntmmmprequires rtoiap a ealsom-quio cournect dter,ImpmvgdemoWhorrepalr `- q any atnduretateme t that pursuant to the lmeuions of st a POWFR DEVICES , O P�I Rk a signed iters statement that he b tissued(commencing t to the Section 70 roof the 7-C ' 3wG Con3aftheusinae dPrlapler9(om)orthathet mmpthcmfm Divi- SWIMMING POOL ELECTRIC TION H O S don basis for Any ortheon of Section 7 erefromand O 9 the bub for the Alleged�ects th applicant Any violation of Section no re any OUTLETS—SWITCHES apphundfora pears(SM. the applicant too dull penalty ofred more than QQ flue hundred dollars(x500). �}T, STORIES TYPECONSTRUCTION NEW RESIDENTIAL ELECTR �n ❑I,a,owner of the property,or rtes employees with wages r thele ole om(Sec.7 KBuldothewmk sessiondrudumkret Intended Llofferedfar vie(Sec.apply to anowess andf property Code The or Improves mpr vestheremcms�Law j$ doe,nonsuch roan owner ofpropertywho nempoyes,proidedthryuch OCC,GROUP RES.UNITS and whodoment.amrnMmee dodo ffe ed own employees,If,ho however, thatsuch Improvementsarenot Intended earofc for vie.If,ho neer- the Wlldingor TOTAL: Improvement kwld wlthinorayearo(cwnpldbMtheowner-W BderwBlhave ttL*rden of Freeing that he did not build or Improve for purpose o(eakd. QTY, PLUMBING PERMIT FEE LJ L as owner of the property,am elusively contracting with licensed FLOOD ZONE APN centradors to mmtmd the project(Sec.7041,Business and Prolemimu Cede: PERMIT ISSUANCE The Contndor's Llmnec Law does not apply to an owner of property who Wilds or Improves themon,and who contracts for such FSajeds with a ALTER-DRAW A VENT,WATER(EA) FEE SUMMARY c L_jI am under ec to the Contractors License Law. BACK FLAW PROTECT.DEVICE LII am exempt limier Sec. B k.P C for this reason DRAINS FLOOR,ROOF,AREA,COND. - SANITARY Y N_ Owner Oats RECEIPT N WORKMAN COMPENSATION DECLARATION FIXTLTRES�PER TRAP SCHOOL TAX Y_ N_ QI hereby affirm that I have a mrnsent re tificam of coto..11-nsu ,or a RECEIPT N m 1ftmteofW.,kera Compm&ui.Insurance ma cerllfkd copy lhmcHFec. GAS EA. PARK FEE - Y 'N 3800,Lab C.) RECFR'f N Policy GAS EA.SYSIEMAVER 4(EA) any BUILDING DIVISION FEES Certified copy b hereby furnished. CREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECKFEE eniffed copy Is filed with the city Inspection division. CERTIFICATE OF EXEMPTION MOM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWER-SANf1•ARY-SNRM EA 310P1• Date RCceI t# (rhiswdion need not be completed Bthe permit 6fv one hundred dollars (S100)mlessJ WATER HEATER W/VENT/ELECTRENERGY FEE Y N I certifythat be the performance o(lhe work for which this permit is Issued, I shall not employ any pence In any manner so as to become subject to the WATER SYSTEM/TREATING Workers'Compensation laws of California.Date PAID O Z Applicant NEW RESIDENTIAL PLMB. SO.Fr. Date Recei t# Z O NOTICE TO APPLICANT:If,after making t his Certificate of Exemption,you should become suis ed to the Workers'Comperuatlon provisions of the Labor TOTAL: F N Code,you=at fort hwlth comply with such previsions orthis perret shall be B W UILDING FEE 1-11- j decreed revoked. - - CONSTRUCTION LENDINGAGENCY SEISMIC FEE d therebyafRrenthattleem baomtmdion lendingagenry forthe perform ELECTRIC FEE O FEE M Z once of the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL' C Lender's Name PLUMBING FEE LL en Lders Address QTY. MECHANICAL PERMIT MECHANICAL FEE OW Iceni(ythat l have read thisapplicatlonand datethattlecabove information CL Iscomot.I agree to complywlth all cityand county ordinances and mate laws PFRMITISSUANCE FEES PAID: . >. W relatingtobuilding constmotion,and hereby authodu repeesentativeeofthi, d toenteru nthe above-mentimeal (mW ion ALTERORADDTOMECH. ~ ? ty(We)agree to save,Indemnify an d kke%p harmle,e th citya C p rtw Date Recei t# .V agaWtlhbilltbs,pdgments, expenmwhichmaylnanywayamue AIR HANDLING UNIT(TO 10,ODO CFM) SUBTOTAL: id byl - lie gnntleg oft his permit. - � AIR HANDLING UNIT(OVER 10,000CIM) CONSTRUCTION TAX 'Igwtureof AppJIN /Co odor qts EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: ZAROOUS MATERIALS DISCLO URE WBl the app karst or(uture building occupant store or handle havrdoue HEATING UM?(TO 100,000 BTU) material as deed by the Cupertino Municipal Code,Chapter 9.12,and the Date RCCCI t# Health and Safety Code Session 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOT ❑Yen M No Will the applicant orfuture building occupant use equipment ordevices VENTILATION FAN(SINGLE READ) ISSUANCE DATE which emit havaMoue air contaminants as defined by the Bay Area Air Quality Management D❑ldrid2 BOILER-COMP DHP OR 100,000 BTU) 4 Ym N No RRyy pp havereadthehav mus material,requirements under Chapter 6.95 of BOILER ICD,000 BTU) Y- A D the Gitfmia Health A Safety Code,Sections 25505,25533 ane 25534.I understa red that lfthe building does net currently have&tenant,that it is my NEW RESIDPNTIAL MECH. SQ'� SEP 28 responsibility to ndlfy the occupant of the requirements which must be met 1x1 prior to Issuance of a Certificate of Occupancy. 1,7 CITY( , V TOTAL: ED Owner or authorleed agent Date - ISSUBY: OFFICE COPY r = 9 rn o� � W �- lU V) N m jFj v / © 2 cd y e GLf L7{� �► �a2S mv [z � :�