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23472 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PERMIT NO. Building Address: (�I 3472 z� a ei. wnen one: A A an,e " CITY OF CUPERTINO-BUILDING DIVISION ontractor's Name: Lic.N. APPLICATION I PERMIT 2 012 W G BU[LDINGQ,ECTRICAI PLUMBINGMECHAMCAL CATEGORY CONTROL# rch AIcer/ ginner. Lk.No: QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO Address: PERMITISSUANCF ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION I hereby d.7000) fDim.i ofChapmr9(mmmenc- APPLIANCES-RESIDENTIAL JOB DESCRIPTION Ingwah 't1an9000)of DlWslon3o(tM1e Buslneasand Pro(esslonsCode,and my license is In full f and effect' PANELS License Class_ Lk.# y`Z.3 i/ G G 4A'r{, s;>• Date_'j� Catered. i eeA��.a. —UP TO 200AMI!q ARCHITECTS DECLARATi9111-1000 AMPS CX I understand my plzru shall be used as public records. OVERIODOAMPS — 'i > y Fr�FIsQQR AREA $/SQ.FT. Ft od`j Licensed Professional SIGNS ELECTRICAL ,� �� _ �_ OOtltl\\VVI' 6 c Om WNER-BUILDER DECLARATION SPECIALCIiCUIT/MISC t t u Ihcmbyaf@m that l am exempt frothe Contractor's License Law for the Z EE R O following reason.(Section 7m1.5,Business and Professions Code:Any city or Z O Z t.8 TEMP.METER OR POLE INST. Kin cnystmm pr arreltsismdte,alsomct,alstheaplimntfrsuch,orretto q �.� any structuretatement that he Is hunseulresthant to the rnialom of to POWER DEVICES t'5 O file a signed statement that he t licensed pursuant to the tion 7000) of the Q6 roC Cantneors License Gov(Chapter9(mmmentlng with Section 7000)of Dlvl- SWUrtMINGP LELECTRIC �0� s1on3.Rhe Business and ProfesslonsCode)orthathebsexemptlherefromand VALUATION 00 the basis for the alleged exemption. Any violation of Section 7031Z by any s..� �< applicant fees permit subjectsthe applicant to a cavil penalty of not morcthan OUTLETS -FIXTURES S .Z �, a ^�^�R flue hundred dolWs($SWI. NEW RESIDENTIAL ELECTR p 7 I,as owner of the property,or my employees with wages as their sole �'�' STORIES TYPE CONSTRUCTION compensation,willdothe work andthe structure is not Intended or offered for p sale(Scc.7066,Busincss.eJ Professloru Code:Tbe Conhadoes License Law r3$ does not apply to an owner of property who Wilds or improves thereon,and OCGGROIIP RFS.UNITS who does such work himself or through his own employees,provided that such improvements are not Intended oroffered for sale.1(howeveq the W ildleg or TOTAL: ImprovementVsoldwithin.neyearofcompldtb theowner-builderwfli�ve ttrwpurdenofproving that he did net Wild or Improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE pLOOD 7pNrp ApN U I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCEcontractorsto condmd the pmject(Sec 7014,Business and Pro/es,ioos Code: ' The Contractor's License Law does not apply to an..or d property who ALTER-DRAIN&VENT-WATER(EN Wilds or Imon proves there , and who contracts for such Imajects with a cpgactdr(s)licensed pursuant to the Contractor'sLicense Law. BAER FLOW PROTECT.DEVICE FEE SUMMARY LJ I am exempt under Sec. B&P C for this reason Owner Date DRAINS.FLOOR ROOF,AREA,GOND. SANITARY Y N WOR KhJAN COMPENSATION DECLARATION RECEIPT# JI hereby affirm that 1 have a certificate of consent to self-insom,re a FD(TURFS PER TRAPSCHOOL TAX Y N udiftmte of Workers'Compev.tionlrourance or a certified mpythemof(Sec. RECENT# 3800,Laab C.)N/�/�/t 7I s nj GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N_ poli # V f• a RECEEPT# Coany (y 6'J/�'� GAS EA.SYSTEM-0OVER BUILDING DIVISION FEES Certited copy Ls herebytumbhe . CREASE/INDUSrRL WASTE INTERCEPTOR PLANCHECK FEE Certified copy V tiled with the city Inspection,dlvislon. CERTIFICATE OF FXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE (Thiasectlonneed notbec.mpletei lithe permit beforone hundred dollars SEWEILSANTTARY-STORM EA.900FF. Date Recei t# (81 W)oifyth WATER HEATER W/VENT/ELECTR ENERGY FEE Y N— I employ an person In an the rnerworso as to b comhis esubjrmite Issued, — I shall not employ any Lam In any manner m u to Wmrre subject to the WATER 5Y67EM/TREATING Worken'CompensaOon Laws of California. Date PAID O Z Applicant Z O NOTICE TO APPLICANT:If,after making l his Certificate of Exemption,you NEW RESIDENTIAL PIMB.__SQFL Date Recei t# should become subject to the Workers'Comperoation provisions of the Labor~ TOTAL:W Code,you most comply with such provision,orthis permit shall be W > deemed revoked. BUILDING FEE (L o CONSTRUCTION LENDING AGENCY SEISMIC FEE = Z I herebyafflrrnthat there B.comtmction lendingagenq forthe perform ELECTRIC FEE anceof the work for which this permit Is issued(Sec.3097,Civ.C.) Torwe; U O Lender's Name PLUMBING FEE LL F Lenders wddnss QTY. MECHANICAL PERMIT FEE MECHANICAL FEE O W Icertify that l have read thisappllcationand statethattheabove Information 1 uouroct.l agree to comply with all city and county ordinances and date lam PERMIT ISSUANCE FEES PAID: >. (L to Wilding consuudlon,and hereby authrx zc representative,of this H Z city to enter upon the above-mentioned property for Inspection purpoxn. ALTERORADDTOMECH. (We)agree to save,Indecently an it keep harmless the City of Cupertino Date Receipt# against liabilities,' dgments,costsand expenses which may in anywayaceme AIR HANDLING UNIT(to 10,000 CFM) SUBTOTAL- agalnst said CiyrV.onaegyptm.(the graining of this permit. /y/ ///77-0" � _rs/^9a� AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX Sigruturc plica /Contractor Dsate ` EXHAUS'T HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will theappllcant orfuture Wilding occupant store or handle hazardous HEATING UNIT(TO 110,000 BTU) Date material as defined by the Cupertino Municipal Code,Chapter 9.19,and the Re:ei Healthand Safety Cod Sedton9.553](a)7 HEATING UNIT(OVER 100,000 BTU) TO Ye, Will the applicant or tore Wilding occupant useequipment ordevices VENTILATION FAN(SINGLERESID) ISSUANCE DATE which emlt hazardous air contardnanh as defined by the Bay Area Air L� Quality Management DsMcti BOILER-COMP QHPOR 100,0W BTU) F+- 4Y;s4'i have read the haza ousmaterlals requirements under Chapter 6.95 of BOILER-COMP(OVER 100,ON BTU) the Gldomh Health&Safety Coda Sectione 25505,25533 and 9:534.I PEAR 31 understand that rosily the buildingductnot a currentlyhavetenant,that it is my NEW RESIDGMIAL MECH. S'Q.PT. V 7oc ) responsibility understand that if theb it ing occupant of the have whichmast beset 1 l//�`�`\+,\� p or�opu ceofaCertificateofOcc�p,ncy. CITY QMK 3 3/-9Z t Ur �r r or authoriad agent Date ISSUED BK7M TOTAL: CCC..."'�rt1 OFFICE COPY