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24284 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PERMITni Building Address: (,I 4 2 8 4 as /s a icA de Pu��o .,v LSA- 9su/ wners aces. one: APPILICA I ION SUBMI I I I A MAaeY &'y'y CITY OF CUPERTINO-BUILDING DIVISION � � Contraaora Naar: LIc,No: APPLICATION / PERMIT AIG 3 2C/`570 BUILDINGELECTRICAL.PLUMBINGMECHAMCAL CATEGORY CONTROL \ Architect/Engineer. Lic.No: S'S o5D QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address:3 &Ieep QJ S A, R e4. PERNUTISSUANCE a ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION T I hereby affirmthat l am licensed under provisions of Cbapler9(commenc APIUANCESRESIUENTIAL � s _IOB DESCRIPTION Ingwilh Section 7000)of Dlvision3ofthe Buainrsaand Professions Code,and my "TW Is In fufd f9{oeapd effect. PANELS License Chas_/f=LLlc Y ./ 70 'A .`,. ^ Date Contactor UPT000 AMPS e4 t' // ARCNITEe used n LARATION OVER 10110 AMPS SQ.Fr.FLOOR AREA $/SQ.FT. �2 I understand my puns shag be used u public records U o Licensed Professional sTCNsa eeTRlcnL 0 �<nt OWNER-BUILDER DECLARATION Yrs' EtSPECIALCBtCUT/M15C IherebyafRmnthat lam exempt from the Contractor's License Law far the AUGQ FOE. following reason.(Seaton 70315,Buelnev and Professions Code:Any city or TEMP.METER OR POLE INST. G 21 fall �pp county which requlresa permit to construct,alter,improve,demohh,orrepalr S.j anystruaure prior to its issaance,aho reiuiesthe applicant for such permit to POWER DEVICES ©©` file a signed statement that he is licensed pursuant to the provisions of the `TTY Contractors License Law(Cha erg mnan with Section 7000)of Divl- 30r^ sion3olthe udnemand Professcome Bns inCode)arthaghebexam therefromand SwLMhtINC POOL ELECI1tIC e VALA the basis for the alleged exemption. Any violation of Sealan17MI5 OUTLETSSWITCHESFlXTURES by any O live hundred dollars($SM. /' <o applicantant(ora permit aubav jethe applicant m a dull Penalty of net ore than c, m NEW REr IDENTIAL ELECTR . ..� �I,ae owner of the property,or my employers with wages as their wle �FISTORIES TYI'ECONSTRUCTION ompensaBan,willdothe wmk,and the structure he not Intended or offered for $ sets(Sec.7W4,Busbessand Pru(esedom Code:The Contractors Ucense law does not apply to an owner of property who builds or Improves thereon,and OCG GROUT' RFS.ANTIS who doessuchwork himself orthrough hlsoweemployees,provided thatsuch Improvements are not Intended oroffered for sale.If,however the Wildleg or TOTAL: improvement hsold within oneyearofcompletion,the owner-bullderw111 have It ten of proving that he did ret build or Improve fee purpose of sale). QTY. PLUMBI IT FEE FLOODTANE AVN n I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE contractors to construct the project(See.7Wk Business and Professions Code: The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT WATER(EA) Wilds or Improves(hereon, and who contracts for such ptojeds with a FEE SUMMARY COnlfado,(,)licensed pursuant to the Contractor'.License Law. BACK FLOW PR EVICT l.J I am exempt under Sec. B &P C for this reason Owner Uate DRAINS FLOO ODE, COND SANITARY RECFR N If WORKMANCOMP DVSATION DECLARATION FIXTURES-PER TRAP SCHOOL TAX Y N F-11 hereby affirm that I have a certificate of consent to self-Insure,ora RECEIPT B certificateofWorkerd Compensation Insurance m a certified copy thereof(See, CAS F.A.SYSTEM-lI O ETS PARK FEE Y N 3800,Lab G.) yzo89-a. Poliq p DING DI M Co any GAS TA.SYSTEM-0VER4 BUILDING DIVISION FEES Cenifled copy h hereby furnished. GREASE/INDUSTRL WASTE EP PLANCHECK FEE CedBled copy 1s filed with the city Inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE STWER-SANTIARY-STORM EA.200Ff. Date eeel t# (This section need na be completed if the permit efm one hundred dollars (SI00)orles.) WATER HEATER W/VEM/FI Ff.rR ENERGYFEeRece'ptff N_ 1 certify that In the performance of thework forwhlch thispermit isissued, I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING PAID Workers'Compensation LawsofCatforrua.Date0 Z Applicant NEWRES DENT ALPLMB. SQFT. Z U N UCETOAPI'LICANT:If,afternuking(hb Certlfkateof Exemp e'you H W should become subject to the Workers Compereation provislom o(Ne Labor TOT l7 CC j Code,you must forthwith comply with such provisions or this permit shall be B 1 W _ deemed revoked. CONSTRUCTION LENDING AGENCY SEIS 'E Il I hereby affirm that them is a construction lending agency for the perform ELE•C Z ance of the work for which this permit is issued(f[3097,CIv.C.) TOTAL: PL G 'EE 0 O Tender's Name MECHANICAL PERMIT FEE LL t- Lendersaddrev QTY. MEC I L FEE U Ixrtilythatl have read thisapplicutona state that theabove Information 0 W bconect.Iagreewcomplywithall citya coontyorellnanees and state laws PERMIT ISSUANCE [rE $PA 1 } d relating to building construction,and herebyauthortmerpresentativesofthls ~ Z dl t entero nthe abovnmentlaud f.H. 1 ALTERORADDTOMECH. Date RCCCIPt# (We)agree to save,Indemnify an d keep�mless tis Cityof CCuppeertUe V againstllablllBes,judgments,cossand expenses which may lnanywayaceme AIR HANDLING UNIT(TO 10,000 CFM) BTOTAL: againg said City In consequence of the granting of this permit. $TRUC77O TAX AIR HANDLING UNTT(OVER 10,(00 CFM)Sigmture of Appllmt/Contractor DateIXHAUST HOOD(W/DUCT) STRUCTION X PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant orfumm building occupant store or handle hazardous HEATING UNIT(TO 100,000 BM Date R ei t# material as defined by the Cupertino Municipal Code,Chapter 9.17,and the Health and Safety Code Seaton 25537(a)7 HEATING UNIT(OVER 100,000 BTU) TNAL: ❑Yn r]No Will the applicant or future building occupant me equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCTE which emit hazardous air contaminants as defined by the Bay Area Air Qaality Management District? BOILER-CAMP Qux OR 100,000 BTU ❑yes �1 NO r Ihave read the hazarsQous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) the California Health&Safety Code,Sections 25505,75533 and 25534.I understand that lithe building does not Currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FI responsibility to notify the occupant of the requirements which most be net . . Prior to Issuance ola I<a • Occupancy. r^' Date Owner or authodmd agent Date TOTAL. ISSUI!D BY: 7 — OF— OpY ....` -