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23102 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Protect Identification LOTPERMIT NO. Building Address: P 23102^1 O 2 en one:: A AA A r: CITY OFCUPERTINO-BUILDING DIVISION 1 2_1 (0- c le Name: Lie.No: APPLICATION / PERMIT l L _b' W BUILDING-ELECTRICAL-PLUMBING-MECHANICAL AT95ORY CO.NO Architect/Engineer. Llc,No: to QTY ELECTRIC PERMIT 171E BUILDING PERMIT.INFO. Add.. PERVITISSUANCE IaGr �/ LICENSED CONTRACTOR'S DECLARATION pppi{pNCISRESIDENTIAL �i� Lia ry I hereby affirm that 1 am Hemsed under provisions of Chapter 9(comment JOB DESCRIFT10N iimose1 In full force)ofd dieonl ofthe Businessandl'rufessiona Code,and my license Ism fun force and effect PANELS LG=(„1•� License Class Lic.N Date {ontmcmr —UP TO 200 AW3 ARCHITECT'S DECLARATION 201-1000 AMPS �q!rc0 Z I understand my plane shag W used as pubbe records. OVER 1000 AMPS SQ.Fr.FLOOR AREA /�$/SQ.Fr. r�,�O Licensed Professional � SIGNSELECTRICAL �, 1 L© .{q 6 re OWNER-BUILDER DECLARATION _` V In• Ei SPECIAL CIRCUIT/MISC tp.., y owing asec.CSatlam31+5,Blromthe ContractorssCodee law forth. , L- Kfollowingreason.(Sectionrmitto,BusinessandrImprove,Code:Any tltyor .. TEMP.METER OR POLE INST. ..7 � county which requlresapemdt to rormtme,alter,improve,dertnlish,orrepair 5 ..� anystructure prior to its Issuance,alsorequiresthe applcantfor such permit to POWER DEVICES g file.signed statement that he Is licensed pursuant to the provisions of the �a Contractor's License Law(Chapter 9(commencing with Section 7000)ofDivi- SWIMMING POOL Fill O sion3ofthe Busmemand ProfemiomCWe)orthat heisexem therefromand VALUATION ^ �E W Q 0 the basis for the alleged exemption. Any violation of Sector 70315 by any OUMETSSWITCI Es Fixf UR saw/ �a.� �+ applicant fora permit subjects the applicant to a civil penalty of not morethan ♦ Y five hundred dollars($500). (wc NEW RESIDENTIAL ELECTR FT. .. ❑1,as owner of the property,or my employees with wages as their sole � STORIES - . 7Y1'E CONSTRUCTION CZ4a rompensation,wnldothe work and thestructurc Is not intended or offend for 9 F❑ to(Sec 7094,Business and Professions Code:The Contractors License law does not apply to an owner of property who Will,or improves thereon,and 5^ who doessuch work himself orthrough hisown employees,provided thatsuch OCC.GROUT' RIS.UNffS - improvementsarenetintendedorofferedforsale.I(however,thebuildingor T T improvement issold within oneyearofcompietlon,the owner-bullderwRl have - rdenofpmAngthathedidnetbundorimprove for purpose of sale.). QTY. PLUMBING PERMIT FEE owner of the property,am exclusively contracting with llmnsed - FLODDTDNE MIN tractors to.istruct the project(Sec.7014,B..Imssanci Professki.Code: PERMIT ISSUANCE e Contractor's License law does not apply to an owner of property who ALTER-DRAIN&VENT WATER(EA) Wilds or Improves thereon,and who contracts for such ptojects with a FEE SUMMARY - ryBllactor(s)Banned pursuant to the Contractor.License Law, BACK FLOW PROTECT.DEVICE • U I am exempt under Sec B&P C for this reason — DIMNSFLOORROOF,AREA,COND. SANITARY Y_ N Owner Date RECEIPT'N �., WORKMAN I hMx aNSATTONDECIARATION FIXTURES PER TRAP SCHOOLTAX Y_ N_ ❑[hereby affirm I have o Insurate'of consent to op thereof ora RECErrp mrtiflab of Worken'Compematton Wuranaoracertl(TNT copythereof(Sec. GAS EA.SYSTEM-1 WCAOUILEI5 PARK FEE Y N 3800,lab C.) RECEIPT N Policy N GAS.EA.SYSTEM.OVrR 4(EA) Cam any BUILDING DIMS NFF.EB ❑Certified copy 6 herebyth the city GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE u^ Certified ropyb(iled with the city inspection division. V O 1 CERTIFlCATGREASETRAP B OF EXEMPTION FROM WORKERS' PAID Lu COMPENSATION INSURANCE a (Thl.sectionneed not Wcompleted Rthe permit foror�e hundred dollars SEWER'SAMTAAY-STORM EA.XgFT. DatC ($1 W)or less) WATER HEATER W/VENT/ErCTR ENERGYFEY �N[ LOJ a.`a I certifythat m the performance of thework for which this permit Is Iswed, I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING Warkcnm Copensation Lawaof California.Date PAID O Z Applicant NEW RESIDENTIAL PCMB. SQ.F. [C Recel t# Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you F should become subject to the Workeri Compensatlon provisions of the Labor - _ TOTAL: N Code,you must forthwith comply with such provisions orthis permit shall be BUILDING rE O W 9 deemed revoked. CONSTRUCTION LENDING AGENCY SEISMI 'E O d Iherebyaflrmthat there iiia construction lendingagenry forthe perform ELEVNIC F4E M Z ance of the work forwhichthis permit Is Issued(Sec.3097,Civ.C.) - — U O Lender.Name PL BI G •EE 1-4 Le F'. Lcoder§Address QTY. MECHANICAL PERMIT FEE 1-4 ,— UW 1certifythatl have read this applicationand matethat theabove Information - �� MECHANI LFEE 1 iscomet.I agnoto comply with all city and county ordinances and gate[am PERMIT ISSUANCE FEES PAID: } relating to building construction,and hereby authorizes representatives of this N city to enter upon the above-mentioned property for inspection pu rposes. ALTERORADDTOMECH. - 2 Date Recei t# (We)agree to save,indemnify and keep eswhi h the City o(Cupe ams U .against liabilities,ncunsequ costs and expense which mayin anyway seem. AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: gains *it City In consary nce of Mgranting of this permit. - , H� AIR HANDLING UNIT(OVER 10,000CEM) CONSTRU NTA orignats Appllcant/Contracto Date EXHAUST HOOD(W/DUCT) CONSTRUCTI TAX PAID: HAZARDOUS TERIALS DISCLOSURE WilltheappBcant or fiihimbulfifingorc,upant store or handle hazardous HEATING UNIT(ED 100,"BTU) Date Recei t# material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code Section 25532(a)? HEATING UNIT(OVER IW M BTUD TO10'F;iMILNil Yen. n No �Villthe eppllcant orfutum building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) ISSUA DATE which emit havrdoua air coramleants as defined by the Bay Area Air Quality Management District? BOILER-COMP OTB'OR 100,0M BTU) p� p ❑No 1f_ -4 1 ID ❑ •I IhYZraud the haxamms materials requirements under Chapter 6.95 of BOILER-COMP(OVER IM,"BTU) the California Health&Safety Code,Sectiom 25505,25533 and•25534.1 C understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECI I. SQ.P ®f f. e responsibility to notify the occupant of the requirements which must be met 19f17 priormissuance ofd CertiBate of Occupanry. CITY x7��rT'i-�J - ur C4f- Ownerorauthorizcd agent Date SSU)ED By: -r — ` s IY T ( OFFICE COPY