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2347 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Bending Pm'aC Identification BuOding Address: PERMITNO. A1*7-11,lell 23477 wn a sure: one (^�:fa� p�� CITY OF CUPERTfNO-BUILDING DIVISION APPLICATION / PERMIT BUfLDINGELECnUIC PLUMBING -MECHANICAL ^�1 paor�mc o 3 DLic No SS CATEGORY CONTROL N Ar,hiteR/Engineer. Lk. No: QTY' ELECTRICPERMIT FEE BUILDING PERMIT INFO [// Address .3 Da �� PERMITISSUANCE 1:1 ❑ ITLICF.NS ED CONTRACTOR'S DECLARATION I herertn(hatlam licensedl underr anenc IngwithS;edton7000)ofDivsion3ofthegusimandPmfeWonsCDde,and my I efuB forte cites. 3 D LlmnseC k.pV AIPLIANCESRESIDENTIA JOB DESCRIPTION av N Y 1 PSP PANFIS Date Contractor20 201-1000 AMPS ARCHITECTS DECLARATIO OVERI"AMPS SQ. FT. FLOOR AREA $/SQ.FL. (understand my plamshall be used as public records. SIGNS ELECTRICAL Licensed Profesalanal OWNER -BUILDER DECLARATION Ihereby afBnn that l am exempt from the Contractors License Law for the following reason. (Section 7011.5, Business and Professions Cade: Any city or countywhich mqulma permitwcomtma, altep impmve, demolish, arrepair n LED IN IPJ r� UTE R SPECIALCIRCUIT/MIST TEMP. METER OR POLE INST. enystmd mpriorwits6mance,as mquimatheapplleanlforsuchpermltto file a signed suatereent that he 6 licensed pursuant to the provisions of the POWER DEVICES - DATE , SWIMMING IDOL ELECTRIC OUTLETSSW17CiIESHXTURES ContractorsLicense Law (Chspter9(commencing with Section 7000) of Divi- cion 3 of the Business and Profeseloro Code) orthal he 6 exempt therefromand the basis for the alleged exemption. Any violation of Section 70715 by any applicant fora permit subjects the applicant to a civil penalty of not room than VAL A ON / +T !/ ysO P NEW RESIDENTIAL ELECTR _SQ.FI'. five hundred dollars ($500).' ❑ I, as owner of the property, or my employees with wages as their sole STORIES TYPE CONSTRUCTION compensation, will do the work and the structure Is not Intended or offered for ' sale (Sec. 7044, Business and Professions Code: The Contractors License Law , _ does not apply to an owner of prore property who builds or improve,theon,and whodoessuch work himself orlhru gh hlsownempleyees, provided that such OCC.GROUP RES. UNITS Improvements are not Intended uro(fered forsals. 1( however thebullding or Improvement 6eold wlihinoneyearafCompletion,lM1e owner-bullderwlil have TOTAL: t rden of proving that he did not build or improve for purpose of sale.). 4 as mucor of the property, am exclusively contracting with licensed contractorsct comtcen the am Code: (Scot appy Business and Iof QTY. PLUMBING PERMIT FEE PERMIT ISSUANCE FLOOD ZONE APN w doe License Law red not apply to an owner of property who pro The Contractor's Improve. Wild. or Improves thereon, and who contrast !or such projccta with a clip[ dor(s) licensed pursuant to the Contradorb License Law, Ll l am exempt under Sec B & P C for this reason ALTER -DRAIN & VENT- WATER (EA) gA�HpWpROTECT. DEVICE FEE SUMMARY DRAINS FLOOR ROOF, AREA, COND. PER TRAP SANITARY Y N a RECEPrFIXTURES- Avner Date WORK MAN COMPENSATION DECLARATION ❑I hereby affirm that I have a of connart to ora SCI{OOLTAK Y_ N o Insurance certificate 8MLab afWorkers'Compensatlon Wuvnce oracertified copy thereof (Sec. c copy 3800, Lab CJ Ztfi9GG —'2` Pollry N _ _ - RECEIPT p CAS E.A. SYSTEM -1 INCAOUTLETS PARK FEE Y N RECEIPT X GAS EA. SYST'Wd OVER 4 (EA) Com any ' BUILDING DIVISION FEES F�Ce Ified copy S hereby furnished, CEJ coined copy 6 filed with the city lope Non division. GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECKFEE CREASE TRAP CERTIFICATE OF EXEMPT ION FROM WORKERS' COMPENSATION INSURANCE (Thissection need not be completed lithe permit 6 (Drone hundreddollars ($1p0)or lea.)WATER l aAifythat in the perfornunce of the work for wN<h (his permn I. issued, I shall not employ any person In any runner so as to become subject to the Workers'Compensatlonlawso(Canfom6. Date PAID Date Recei t# SEWER-SANITARY-SMRM EA. 200FC. HEATER W/VENT/ELTlTR ENERGY FEE Y N — PAID WATER SYSTEM/TREATING Applicant NOTICE TO APPLICANT: after making this Certificate pr is Exemption, you should become subject to the Warken'Compensatlon provlstons o(the Labor Code, you must forthwith comply with such provisloru or/hls pemdt shall W revoked. Date RCCCI t# NEW RESIDENTIAL PLMB._SQpr. TOTAL: s,, --adeemed U WING -TOTAL: SEISMIC FEE ELECTRIC FEE` CONSTRUCTION LENDING AGENCY Iherebyaf,.thatthere 6amnstructlon kndingagenryfortheperform once of the work for which this permit is Wood (Sec. 3097, CIv. C.) fender'. Name Lenders Addrea nand statethatthe above I certify(hm I have read fhbth QTY. MECHANICAL PERMIT FEE PLUMBING FEE MECHANICAL FEE FEES PAID: 6correct.lagree to comply with andlyand county ordimncesand mate allcityd mate laws PERMIT IBSUANCE relating ronstruNo,eendherebyauthorize representatives o(th6 terupont ci (Wellto agree to sae, Indemnify an property harmless Cit purposes. (We) agree to ave, Indemnify an d keep harMes the City of Cupertino against liabilities, pdgmente, emisand expenses which may in anywayaccrue .g. red vl Try In en rt grantingof � tM1l. nnit �� ALTER OR ADD1D METH. AIR HANDLING UNIT (TO 10,000 CFM) Date Recei t# SUBTOTAL: AIR HANDLING UNIT (OVER 10,000CFM) CONSTRUCTION TAX Ignatvre of Applicant/Cehotracior Date EXHAUST HOOD (W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT (TO 100,000 BTU) Will the applicant the ure budding occupantods, hapten ie hazardous material as defined by the Cupertino Municipal Coda Chapter 9.12, and the I and Safety Code SeRioo 25532(a)2 ❑ Yes No Date Reepl TOTA HEATING UNIT (OVER 100,000 BTU) VENTILATION PAN(SINGLE RESID) ISSUANCE DATE p a1 q .SR �\ 'T \/4`eV`/ Clry� NO? Will the applicant or future building occupant use equipment or devices which emit havrdoua air contandnante as defined by the Bay Area Air Quality Management District? Yesn4 No have read the bsadrama.ficr66 requiromenb underChapter6.95of the Ce1Rom6 Health & Safety Code, Sections 25505, 25533 and 25534. 1 u red ersta nd that if the building does not eu mently have a tenan((hat it I, my responsibility to notify the occupant of the requirements which most be most prior to exuance of a Certificate of Occupancy. BOILER -COMP QHPOR 100,000 BTU) BOILER-C'OMP(OVI➢i 100,000 BIU) NEW RESIDENTIAL MECH. SQ.17 h 2 ISSUED Bu Owner or authorlud agent Data TOTAL: OFFICE COPY