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20243 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification VnbLGo 141,w Hk PERMITNO. Bu Bre dn�2dd ,,:N .N oL t 20243�cD ., S�I, ggs ,Na o„� VV 33 hone CITYOFCUPERTINO-BUILDINGDIVISION A A C tractor's Name: ,Y Lie o: APPLICATION /PERMIT e edza- `SS BUILDING-ELECTRICALPLUMBINC-MECHANICAL CATEGORY Architect/agloar. I Lit,No: A1144d—l ” lh&ff �n QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO Addmss: ' 0' IVJ91 7N(6 Uri, PFRMITISSUANCE ❑ ❑ ❑ m LI . CF NSEDCONTRAOR'SDEC RATION q((/,x� - I hereby affirm that l alicensed under provisions of Chapter9(commen APPLIANCESRESIDENTIAL JOB DESCRPI'ION Ingwlth Sect(on7000)of DiWs(on3ofthe Buslncsand Pmfe =s Code,and my license la In fullfora and effect PANELS License Clas LicaLT` \— Date Ctmmactor v ARCHITECTS DECLARATION 701-1000 AMPS q�+ocI understand my plans shall be used.public records. OVERIOOOAMPS SQ.pr.FLOOR AREA $/SQ.FT. 00 ie UF, Licensed Professional SIGNSELECTRICAL •7(-,a� �r < OWNER-BUILDER DECLARATIONlhateTom-sT'!7"� �Or �� �n "qcee SPECIAL CIRCUIT/MISC L, owing raf@mthatlam31.5,B(ro ossa Contractsions Code:Law fort he Fg7 follow(ngreasmquimsapeon 3ttoco tmdand Pimp .me=te hnycity ormpair TET,.(p,METIA OR TOLE INST. 7 �(/ x anystm�ntympriorlreiapwa ttoc.vtuuimtheapromntforsuch, er tto Vu �YY Q any structure patemenbhat he Is ohoredpursuant to the provisions t e POWER DEVICES C�U file a signed statement that M Y licensed pursuant to the provisions of the Contractors License law(Chapter 9(commencing ncin with Section 7000)of Divi- VALUATION w ss B SWIs1MING POOL ELECTRIC O Yon3of the Business and ProfsalonsCode)orthat hes exempt therefromand p~ Sn S the bash for the alleged exemption. Any violation.f Section 7031.5 by any OUTLETSSWITCHESHXRIRES applicant fora permit subjeceathe applicant a civil penalty of not enrethan Cc � � five hundred dollars($5M. NEWRESIDENTIALELECTR SQF7. SLOW TYPE CONSTRUCTION .. �1l as owner of the property,or my employees with wages as their sole kit compemafion,:21 dothe work,and thestructure is not intended or offered for O Cela(Sec.7044,Business and Professions Code:The Contractors License Law 1;7 5 S does not apply to an owner of property who builds or improve thereon,and OCC.CROUP RES.UNITS a who does suchw.rk himself or through his own employees,provided that such improvements are not intended or offered for sale.If,however,the building or TOTAL: improvement Esold within one yearof completion,the owner-builder will have t Nen of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN 184 v owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE tractors to construct the project(Sec.7044,Business and Profesbns Code: The Contractor's License law does not apply to an owner of property who Wilds or improve Uaeon, and who contracts for such ptelacb with a ALTER-DRAW&VENT-WATER(EA) PIcm4s)licensed pursuant to the Contractor.License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY a exempt under Sec B &P C for this reasonOUTSIDE FEES Own Date DRAINS FLOOR ROOF,AREA,GOND. SANITARY RECEIPT WOR KN COMPENSATION DECLARATION p0(TIJRES PER TRM SCITOOL TAX Y_ N_ ❑1 hereby affirm that I have a ecrtllate of consent to self-Insure,or RECEIPT N certificate ofWorkers'Compensation Insurance or a artified copy thereof(Sec. 380),lab C.) S GAEA.SYSTEM-t INC.4OUTLETS PARK FEE Y_ N_ Policy p EA.SYSTEM-OVER 4(FA) RECEIPT 0 Com any RUI LDING DIV]SION FL LS �Certiied copy IS hereby W red,hed. EASE/WDUSTRL WASTE INTERCEPTOR PLANCI-IECK FEESS �Ceri ied copy b filed with the city Inspection division. CERTIFICATE OF EXEMPT ION FROM WORKERS' REASETRAP PAID S1so {J�z F�r°a COMPENSATION INSURANCE SEWER-SANITARY-STORM F.A.200FT. Date RCmI t# (Thissectlon need not becompleted if the permit lafor nehu dollars (slln)or lea+.) WATER HEATER W/VENT./F3,ECTR ENERGY FEE Y_ N_ I artifythat in the per(o sof the wakfor wMch rmitlatarou I shall not employ any pe 1 any rtanner n ns to become aabject to the W, EATING Worker%Compensation laws llfornb. Date PAID_J_L_l SSM_ 0 Z Applicant R D LPLMO. SQ.FT. Date Remi t# Z NOTICE APPLIC ,after trading this Certificate of Exemption,you shouldVyfb' ' trot a darn Compereation provisions of the Labor TOTAL: _ � W Code, rt with comply with such provisions orth perms. BUILDING EE W ] IS CONSTRUCTION LENDING AG�NyCYSEISMIC FEE athatthere&am to on to III uy( t rfornv TOTAL: ELECTRIC FEE 7 Z arrv.fthxw.rk forwhichthia permitsblued(SedV3o' Civ. . (� O_ Indere Name PLUMBING FEE LL F Inder.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE O Icortlythat l lave read thisapplloUonand state thatthe above Information FEES PAID O W bcomet.Iagree to complywith all city and county ordinances and Yate laws PERMIT ISSUANCE >. a relating to building construction,and hembyauthorturepresenlativeaafthis (_ Z city to enter upon the above.reentioned property for impaction purposes. ALTERORADDTOMECH. Date Receipt# (We)agree to save,lndemNty an d keep harrelain sse the City of Cu pen . V agabat liabilities,Judgments,ones and expenses which may In any way am /dR HANDLING UNIT(7010,000 CFM)us SUBTOTAL: O ago Wt u� ity In consequence13 f the granting of this permit. AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX Signature of Applicant/Contractor Date EXtIAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Reeef t# material as defined by the Cupertino Municipal Code,Chapter 9.17,and the licalth and Safety Cade Section 25532(a)7 FIEATING UNIT(OVER 100,000 BTU) TOTAL: 3 11.43 ❑ Yes M No Wllllhea ppllont or hIm.building occupant use equipment or devices VENTILATION FAN(SINCLE RFSN) ISSUANCE DATE ' which emit haardousabcontamimts as defined bythe Bay Area Ale Quality Management District? BOILER-COMP DHPOR 100,000 BTU) PAM D. '?ye, QNo i� have read the hazy ous materials requirements under Chapter 6.93 of BOILER-COMP(OVER 100,000 BTU) JUN IL's y IJJV n('� I the Calif orniaHealth&Safety Code,Sections 23505,23533 and 25534. I understand that lithe building dos not currently have a tenant,that it b my NEIN RESIDENTIAL MECH. SQ.FT. responsibility to notify the occupant of the requirements which meat be out p ,y prior to Issuance ofaCertiOcate of Occupancy. City of Capeeflno Owner or authorimd agent Data TOTAL: ISSUEDBY: �] OFFICE COPY