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23147 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PERMITNO. Building Address: 23147 os Z-o ane: one: A A Cpe 0— {4A-(V 4 CITY OF CUPERTINO-BUILDING DIVISION G t a SNa : LIc,Ne APPLICATION / PERMIT L� ` BUILDING-ELECTMCAI-nUMBING-MECHANICAL CATEGORY CONTROL N rchitet/Engineer. Lie Nee QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO'- Add.. APERM7TISSUANCE ❑ a LICENSED CONTRCTOR'S DECLARATION I hereby affirmthat l amlicensed under provisions of Chapter9(commeno APPLIANCES-RESIDENTIAL - JOB DESCRIPTION Ingwilh5ection 7000)of Division 3ofthe Businessand profession.Code,and my li¢nx is in fir !a cad effect PANELS I Lken Cb Lk.N - �rGE Q I v`rVjW, Date Contractor / ARCHITECTS DECLARATION 201 TWO ANTI'S 2 I understand my plans shall be used as public rerords.. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT. QOLlmnxd Professional SIGNSELECTRICAL A L E D i Z, OWNER-BUILDER DECLARATION SPFf_1ALCIXCUIT/MISC n n �� p, Z Thereby affir.nthat lam exempt from the Contractor's License Law for the Iv' PU d 9F F Q following reason.(Section 70115,Business and Professions Code:Any city or TEMP.MEIFR OR POLE INSf. 5p ul county which requires a permit to construct,alter,improve,derneish,or repair / I Q anystructure priorto its Issuance,also requlrosthe applicant forsuch permit to POWER DEVICES �( ` c.O file a signed statement that he is licensed pursuant to the provisions of the y � s Contractor's License Law(Chapter 9(mmmenclng with Section 7000)gf Divi- BWA3M NG TOOL ELECTRO VALUATION sion3 ofthe Business and ProfesslonsCode)orthat he is exempt therefromand L5p1 the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWITCHESFIXTURFS applicant fora permit subjects the applkan/to a civil penalty of act more Hun c. o five hundred dollars($SW). NEW RESIDENTIALELECTRFT. 7< ❑I,as owner of the property,or my employees with wages as their sok STORIES TYPE CONSTRUCTION compensation,will do the work and the structure k not Intended or offered for 5 D salt(Sec.70K Business and Prdessioro Code:The Contractors License Law Q does not apply to an owner of property who builds or improves thereon,and '$^ who does such work himself orthrough his own employees,provided that such OCC.GROUP RFS.UNITS improvements are not Intended proffered forsale.If,however,thebuiiding or TOTAL: improvement usold within oneyearofcompletion,thee ner-budderwill have thI,,� rdenof proving that has did not build or Improve for purpose ofsale.). QTY. PLUMBING.PERMIT FEE FT.ODD TDNE APN LI Las owner tr the property,am exclusively contracting with I PERMIT ISSUANCE �r contractors to ronawct the project(See.appy Business and Professions C.de:Code: The Contractor's License law does not apply to; t owner of property who ALTER-DRAW k VENT WATER(EA) builds t r improves thereon,and who tra tats License p.ojecb with a FEE SUMMARY cQ➢tlactor(sexempt licensed under ee to the Contractor's Lkenx law. BACK FLOW PROTECT.DEVICE LJ I am exempt under Sec. B k P C for this mason OUTSIDEFFES DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N Owner Date RECEIPT N WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAla SCHOOL TAX Y N F-11 hereby affirm that I have a cortlficate of consent to self-Insure,ora RECEIPT N certificate ofWorkers'Compensationlvuranmmacertifled copythereof&$ . GAS FA,SYSTEM-1 WCAOUTLETS PARK FEE Y N 3800,lab C0 RECEIPT Policy CGAS EA.SYSTEM-OVER 4(EAJ nm - BUILDING DIVISION FOES Certltled copyb herebyfurnlshed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE ❑Certified copy is filed with the city Inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID COMPENSATION INSURANCE $FWER$pM.LARY9�2RM-61:2IXIF1. 1 / Date RCceI [# Rhtssectlon need call becompleted if the permit kfgrone hundred dollars i (S100)atifyth WATER HEATER W/VENT/ELECTR ENERGYFEE Y N Icertily that in the performance o(the work for which this permit is Issued, - I shall not employ any person In any manner an as to become subject to the WATERSYSTEM/TREATINX; Workera Compensation Lawa of California Date PAID O Applicant Date Recti t# Z NEW RESIDENTIAL PLMB. SQ.FT. Z O NOTICE come suLICAtothe ori making s'Com er Certif.tion catepro is Exemption,you should becomeforth to the Worker'Compensation provisionsofthe Labor TOTAL: WW Cgdgyau most forthwith comply with such provlsiov or this permit shall be BUILDING FE' W ] dremed revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE CL ]hereby affirm Uthem Lsaconstruction agency perform,Z agmworkfor Which thb permitVLasved(Sec.3097lCh'.C.) T T ELECTRICFEE OI<naee.Nme PLUMBING FEE F Lender.Add... QTY. MECHANICAL PERMIT FEE LL MECHANICAL FEE O W Iriver.I agrees complye read in with aBcatynand dcstate tordiancesa andgate la n a lacornet.building comply all dtyandmuntyes,repnceaandtsofthis PERMIT ISSUANCE PEES PAID: } cityrelating tobuilding t mnstroctrantiod d rebyprop rty or in representatives of this F N cityWenter ee to the indemnify an Lopertytor inspection purposes. ALTER OR ADDTO MECH. Z (We)agree m jade,Indemnify an d keep es Which the City of Cupertino Date ReOTAL V against liabilities,judgments,costaand expenses whnch may In any ways¢rue AIR HANDLING UNIT(TO 10,000 CFM_) SUBTOTAL: Z7 said City In consequence of the grant mg of this permit AICONSTRUCTION TAX R HA UNIT 1p,lD0 CIM] Signature of Applicant/Contractor Date ExHAUSrI IOOD(W/DUC'D - CONSTRUCTION TAX PAID: HADA RDOUS MATERIALS DISCLOSURE Will the applicant or fixture building occupant store or ha cad le harardom HEATING UNIT(TO 100,000 BTU) Date Recei t# material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the health and Safety Code Setiyn 2532(a)P HEATING UNIT 100,000 BTU) - TOTAL.,- El . ��- ❑Yes �'laO Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE Quality ithaengnt Diitrict?contaminants as defined by the Bay Area Air P A I D, which emit Mt ha,mr ou Dlstri nt BOILER-COMP DTN OR 100,000 BTU) ❑ Ye II-L�-I��o I have read thehuatruce materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) the Chfuunderstand t Health doSafety Code, otcurrentlyhections 25533 ve.tend,that. I DEC 31 1991 uedersmndthat lfthe building eoccupsm aft errentlyharta hich,thatitiamy NEW REST DFN77AL MECH.' SQ.Ff. eesponsibilitymrally the occte of ofrherequuemenls which nwstbenM r to Issuance eetof rtificaze of Ocmpanry. CIIY Ula CUPEH Inu neeauthoriizd agent Date ISSUED BY. TOTAL: OFFICE COPY