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23876 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Pm'eat Identification PlutMITNO' Building Address: 23876 74 sus C� QAl Rb, ween arty: - one. CITY OF CUPERTINO-BUILDING DIVISION APPLICATIONSUBMIFLALDAIJ Gn aetnrsNam LIe. APPLICATION I PERMIT gmear: i KI a S BUILDING-ELECTRICAUPLUMBINGMECFIAMCAL CATEGORY CONTROL N tect rchi /Engineer: Lk.No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address PFJ1hITISSUANCE 1:1 E] El CONTRACTOR'S DECLARATION I hereby Wirmthat lam Vcmzd under provisions of Chapter9(rommmc APPLIANCESRESIDENTIAL JOB DESCRIPTION Ingwlth5m1an7000)ot Divblon3 ofthe Buslneuand ProfeaslontCnde,and my llmeselalnfull nd effect. PANELS /��► yy�� a, Liam C as LIc.N-5,8.33) v�� Kbrl Data Contractor Iev '{� ARCHITEC7PS DECLARATION 301-1000 AMPS al �'Z I understand my plana shall be used a a public records. OVER1000AMPS SQ.Fr.FLOOR AREA $/SQ.Fr. CO U() LlccnaM Professional SIGNS ELECTRICAL �Q OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC 7s, 7a Ihercbyaffirm that l am exempt fmmthe Contractor's License Law for the . Pp following reason.(Section 7031.5,Business and Professions Code:An eft ent � y Y or TEMP.METER OR POLE INST. � � muntywhlN requlmea pertNt tomnstmQ,siren improve,demoWh,orrepalr �k anystmdum pectin Its issuance,alsorequires the applicantfor such permit to POWER DEVICES file a signed sounzet that he is licensed pursuant to the provisions of the 3w Contractor'sLicense Law(Chapter9(mmenereingwithSection 7000)otDivl- ��03 sion3ofth.Bualnmand ProfessimsCode)orthat heisexempttherefromand SWIMMING POOL ELECTRIC VALUA'7� O the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESHXTURES applicant for a permit subjects the applicant to a civil penalty of no room than fiven 1,hundreddollarsof hepr. NEW RESIDENTIAL ELECTR STORIES 3YPECONSTRUCTION u as owner of the property,or my employees with wages as their sole �'IT' compensation,willdo the work,and thestructure is not Intended or offered for OIn&c.7044,Business and Prolamines Code:The Contractors License Law doesnot apply to an coven,of property who builds or improves themes,and EE who does such work himself or through his own employees,provided that such OCC.GROIIIa RLS.UNITS Improvements arc not Intended oroffered for safe.If,however,thebullding or TOTAL: Improvement issold with noneyxarofcompletioMtheowner-bullderwill have tilgpu as of proving that he did not bund or improve for purpose otsals.). QTY. PLUMBING PERMIT' FEE }7pp zc NNE APN LI i, s owner of the property,am exclusively contracting with licensed PFAMI T ISSUANCE contractors to construct the preject(Sec 7044,Business and Professions Code: The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA) builds or Improves thereon, and who contracts for such pkajects with a cgB(raaor(s)Reamed pursuant to the Conlranoes License Law. BACK FLOW PROTECT.DEVICE 'FEE SUMMARY I�I am exempt under Sec B k P C for this reasonOUTSIDE!,FFE9 Owner ate DRAINS OF,AREA,COND.FLOOR ROOF, SANITARY Y N Dp WORK MAN COMPENSATION DECLARATION RECEIPT '40 01 hereby affirm that I have a certificate of consent to eelf-Inarre,ora FD(TUJRES PER TRAP SCHOOL TAX Y NRECEIPT 3800,Isis C.) certificate ofWorkers Compevatlonlruurance ora ceel(led ropy thereof(Sec. GAS EA. INCINC.40UTLEI'S PARK FEE Y N -I/� RECEIPT q cy Com CAS EA.SYSTEM-OVER 4 MA) BUILDING DIVISION FEES Com Cfied ropy is filed with tpy is herebytht he city Inspection division.ed. GREASE/INDUSIRL WASTE INTERCEPTOR PLANC14ECKFEE ❑ CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID COMPENSATION INSURANCE SEWFR.SANITARYMRM EA 200FT Date Rccei t# Rhin section need not he completed lithe permit is forces hundred dollars (s1I0)orfcertify that WATER I-EIATER W/VENT/ELECTR - ENERGY FEE Y N I ll nor that emIn ploy an person in an thework an as t become esubjecrmit Is ho heed, — I shall not employ any person In any manner at u to become abject m the WATER SYSTEM/TREATING Workcn Compenaatlon Tawe of Gllfomb. Date PAID OZ Applicant Z 0 NOTICE TO AIsI'LICANT:IL after making this Certlflcale of Exemption,you NEW RESIDENTIAL PLMB. SQ.Rf. Daft Rece1 C# Hshould become subject to the Wor4enCompereatlon provisions of the Labor TOTAL: CC N Code,you at forthwith comply with such provisions orthis permit shall be BUIL �^ W > deemed revoked. - CL CONSTRUCTION LENDING AGENCY SEISMIC FEE I hereby affirm that there is a construction lending agency for the perform- ELECTRIC FEE C Z ance of the work for which this permit is tasted(Sec.3097,Civ.C.) TOTAL: V O Landers Name PLUMBING FEE LL I— Under'.Add... QTY. ''MECHANICAL PERMIT FEE' MECHANICAL FEE OO l certifythat l haveread thisapphotionand statethat theabove Information C 111 is mrtect.I agree to comply with all cityand county ordinances and state laws PERMIT ISSUANCE FEES PAID: relating to building censtmctlon,and hereby authorize representatives of this H city to enter upon the above-mentioned property for Vupection purposes. ALTER OR ADDTO MECH. FDate Revel t# (We)agree to save,Indemnify an d keep harmless the City of Cupertlno P against Illties,od is,costs an expenses which may In any wayacerv, AIR HANDLING UNIT(TO l0i CFM) SUBTOTAL: agai Id City In f egrenting of this ported �J' AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX Slgmture of Applicard/C.,fintractorDita EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS TERIALS DIS CLOSURE Will the applicant orfuture building occupant store or handle hazardous IDEATING UNIT(TO 100,MD BTU) Date RefClpt# material as defined by the Cupertino Municipal Code,Chapter 9.12 and the Health and Safety Code Section 75533(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: ❑YeaM No Will the applicant or futumbuilding occupant use equipment ordevices VENTILATION FAN(SINGLE MID) . IS$UANC'''QATE mi which et havrdous air mntaminantt as defined by the Bay Area Air `Pict Quality Management District? BOILER-COMP OHP OR 100,000 BTU) q Yea 1—I Na 10 - understand ealthhe ar�et mode,Sections 2555,2553 r Cha peer and25534.15 of BOILER-COMP(OVER 1fl0,Of10 BTU) �� the erstan t Health building Code, otcore75505,watand25534.I ,1 1('+� understand thatn ify the oco poet of erequire ent which that Rismy NEW RESIDENTIAL MECH. SQ.FT V responsibility igueo to not fa Cert occe of Occ the requirements which rrwst be rtes ax uFtC'r/1� Prior to Issuance ofo Certificate of Occupancy." � ,I7`J(' Owner or authorize a gent Date TOTAL: ISSUED BY OFFICE COPY