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24247 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY Bulldln Yre'eR Identification PERMIT NO _.I{ulldinRg Addmsa: 24247 Y wnere ams: k"I / one: ATr CITY OF CUPERTIN&BUILDING DIVISIONAM n��N1l� M� contractor's Name: LIe.No: APPLICATION / PERMIT -I l;-q LtJ/dL �� BUILDING-E.ECTRICALML BINGMMCH MCAL CATEGC)RY CONTROL# ArchltM/Gglneer. Lk.Na; QTY ELECFRICPERMIT FEE BUILDING PERMITINFO Address: actee nLICENSED CONT'RACTOR'S DECLARATION PERMITISSUANCE �❑ ❑' ❑ IhermthatIamlknunder provisions Chapter c- MPWANCESRESIDEMIAL JOB DESCRIPTION IngwthScctFon700 DIvf3oftheBuslnessandPralessionsCode,and my licene b In full and effect. C21416rPANES d�,-+tV, eq'4! CLkntpactor u201-1000AMPS ARCHITECT'S DECLARATION OVERI000AMP5 SQ.FT.FLOOR AREA S/SQ.FT. a0 7 I understand my platy shall be used az public records.COC (j Licensed Professional SIGNS ELECTRICAL OWNER-BUILDER DECLARATION SPECIALCIRCUfT/MISC i.., 7 IWorbyaff.that l am exempt from the Contractors License Law for the F4 following reason.(Section 7MI5m,Business and Professions Code:Any city or TEMP MEfE20RPOLEINST. E 8 countywhkh requlresa permit toconstct,alter,Improve,demolish,orrepair a any structure prior to Its Issuance,also requires the applicant for such permit to ROWER DEVICES a V file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9(commencing with Section 7000)ofDivi- SWIMMING POOL ELECTRIC VALUATION O sion 3ofthe Businessand ProfessionsCode)orthat he 6 exempt therefromand the basis for the alleged exemption. Any violation of Section 70315 by any OUMETSSWTTCHESFD(TURES 10, 0C90 appliantfor.permit subjermthe applicant to a civil penalty of not nom than c. five hundred dollam%500). NEW RESIDENTIAL ELECTR .FT. [:]1,as owner of the property,or my employees with wages as their sole STORITS TYPECONSTRUCTION compensation,wlllelothe work,and the snuctem 6 net Intended or offered for OIn(Sec.7044,Business and Professions Code:The Contractors License Law Q does not apply to an owner of property who Wilds or Improves thereon,and OCC.GROUP RES UNITS a who does such work himself or through hisown employees,provided that such improvements are not Intended oroffered for sale.If,however,thebuilding or TOTAL: Improvement bsold with noneyearofcompletion,the owner-bullderwlll have - tkn rden of proving that he did not Wild or Improve for purpose of sale.). QTY. PLUMBINGPERMIT FEE FLOOD ZONE APN LJ L as owner of the property,am exclusively contracting with licensed PELMIT ISSUANCE contractors to construct the project(Sec.7044,Business and Professions Code: The Contractor's License Law does not apply to an owner of property who Wilds or improves thereon, and who contracts for such pRojects with a ALTER-DRAIN&VENT-WATER(EA) q�(factor(s)licensed pu rsuant to the Contractor's License Law. FEE SUMMARY c LJ 1 am exempt under Sec. B &P C for this reason BACK FLOW PROTFLT.DEVICE OUTS I DE FEES DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_ . Owner Date RECEIPT p WORthIO .N�S COMPENSATN DECLARATION FIXPER TRAP SCIdOOL TA% Y_ N_ ❑I hereby affirmmthat 1 have a certificate of consent to self-inmm,or a RECEIPT N certlflamofWorkers'Compensatlon Insurance eea crifif/ied copythereof(Sec. GAS FA.SYSTEM-1 INC OUTLETS PARK FEE Y_ N 3800, Y WbCJ WP a�r� I[��J4A-�� 7TRECEIPT# Po11ryT^3 GAS EA.SYSTEM-OVER 4(EA) Com sass P✓d-( � ,t� BUILDING DIVISION FEES �CenlOed copy 6 hereb;in meshed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE ❑Certified copy Is filed with the city Inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWER.SANTTARY-STORM FA"FT Date RCLY'1 IN (Thissection need not be completed lithe permit is for one hundred dollars ($100)orless.) WATER HEATER W/VENT/19.FOTR ENERGY FEE Y_ N_ I mrtlfy that in the performance of the week for which this permit Is Issued, 1 shall not employ any person in any manner so as to became subject to the WATER SYSTEM/TREATING Workers Compensation Laws of California Date PAID O Z Applicant NEW RESIDENTIAL PLMB. SQ.IT. Date Remipfl ZO NOTICETO APPLICANT:If,after makingth6CeAt lute of Exemption,you Hy should becomesubject to the Worker'Compensation provisions ofthe Labor TOT __ Q CC ; Code,you most forthwith comply with such prov6kns orth6 permit shall be BUILDING6J`� LU _ deemed revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE l d [hereby work for w them 6acowtmctlon lendiagagency Sec.307,Civ.rtbe pedorm- TOTAL: ELECTRIC FEE if 0 Z anceofthc workforwhkhth6 perMt66sucd(Sec.3097,CIv.CJ PLUMBING FEE 00 lender's Name if LL H Under',Address QTY. MECHANICAL PERMIT FEB MECHANICAL FEE U Icertifythat l hawmad this application and statethatthe above Information O W 0corrtct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID: } 0. mlating tobullding ronsnucdoo,and hereby authorize representatives of this Z city to enter upon the above,mentioned property for Inspection purposes. ALTERORADDTOMECH. (We)agree to save,Indemnify an d keep harmless the City of Cu pertlno Date eeciptN V agaWtll illtks,pdgments,coae expenxa which mayinanywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) S TOTAL: aga0u AI Id City In consequence gr tingd permit. �. R HANDLING[INR(OVER 10,000 CFM) CONSTRUCTION AX ure of App i t/C,mfi.ctr Date EXHAUSTFOOD(W/DUCT) CONSTRUCTION AX PAID: HAZARDOUS MATERIALS DI SCLOS URF. RRIB the appllca nt orfutum building occupant store or is ad In hazardoua HEATING UNTT(TO 100,000 BM Date c�tlf material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the — - Ilea llhand Safety Cod n Section 25532(a)2 HEATING UNIT(OVER 100,000 BTU) T ALIt ❑Yes M No Will the applicant orfutumbuilding occupant use equipment ordevices VEN77LATION FAN(SINGLE RFSID) ]$$UANCE� ATE which emit haranious air contaminants as defined by the Bay Arca Air Quality Management DWrle2 BOILER-COMP DHP OR 100,0(0 BTI) IRYca I No SEP 18 1892 ave mad the hazer ous materials requirements under Chapter 6.95 of BOILER-COMP(OVE2103,OW BID) the Califern a Health&Safety Code,Sections 25505,25S33 and 25534. I /x understand that if the building does not currently have a tenant,that It 6 my N EWRESIDENTIALMECIi. SQ.IT CITY Ur v responsibility to notify the occupant of the requirementswhich must be met prior to issuance&a CerORate of Occupancy. Owner or authodred agent Dale TOTAL: ISSUED BY: OFFICE COPY