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24006 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES'- USE BALL POINT PEN ONLY Building Project Identification Pl- M TNO. 0ullding Address: J� . 24006 1.ys'o �a �s fiuwN l/ Y � P��!'. v• Phone: _ lLi'U Tvr�Pr .2S3"Rlas CITY OF CUPERTINO-BUILDINGDIVISION ContradoYa a Lic.Nex APPLICATION if PERMIT 7 2-2• Ci Architect/Englnrer. Lk.No: BUILDINGFLECTRICAL-PLUMBINGMECHAMCAL CATEGORY CONTROL N QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: POWTISSUANCE - - ❑ - LICENSED CONTRACTOR'S DECLARATION - Iherebyafflrm that l am licensed under provisions o(Chapler 9(commen APPUANCESRESIDENTAL JOB DFSCRNHON ingwith Sedimn7000)of Divi.i.3afth.Buinessand PmfeskonsCodgand my Itce,ae Is In full force and effect. PANELS . Lithe Class Llc.N \�"F. re uk ©� Dale Contractor ' ARCHITECT'S DECLARATION 201-1000 AMPS 070, l understand my plana shall be used as publicrecords. OVER1000AMP5 SQ.FT.FLOOR AREA S/SQ.FT. • Fi U Licensed Professional SIGNS ELECTRfcAL © �,, <6 OWNER-BUILDER DECLARATION u V, P U T I`n] SPECIAL CIRCUIT/MISC L. Zf, 14 [hercbyafflrmthaU e am exempt lromlM1e Contractor'.License Gwlor the following mason.(Sce lon 70115,Business and Professions Code:Any city or F, f•e countywhichrequlresaper ttoconstma,alter,impmve,dennllah,ormpalr TEMP.METEIi OR POLE INST. eM`S ,aa anystmmare priortolts Issuance,also requlrnthe applicant for such permit to POWER DEVICES V file a signed statement that he Is licensed pumuset to the provisimu of the E OK Contact.,'.License Law(Cha er9(¢mncin with SWIMMING IDOL ELECTRIC E,��g sion3olthe Bu.inea..andl'rofessbnsCode)orthat he Isexempt themfromand VALUATION OQ the basis for the alleged exemption. Any violation of Section 7011S by any OUTLEISSWITCHESFIRTIIRFS Q D applicant fora permit subjects the applicant to a civil penalty of not room than 1 _0 O E � flv6un redt as of pN. - NEW RESIDENTIAL FLECTR SQ.FE. STOW TYPE CONSTRUCTION <n e s owner of the property,or my employees La with wages thele sale - _ C compensation,willclothe Business and Professions Code: rehe va IntendedContactor,or License d for Law 2�O vk(Sec.apply to Business and f propebre Code:The C Impooves hemon law $ does whodocieuchtoanownerdthroug ywhobuilds orlmprwvided t oRand OCC.GROUP RES.UNITS whodoeseuchworkhinaelf mrlhrmugM1 hlsownemployeea,provided that such _ Improvements arc not intended oroffered(¢sale.If,however,thebuilding or - i TOTAL: ' Improvement lasold withinoneyearofcompledon,the owner-bullderwlll have Video of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE F[.00D7DNE APN 1,as owner of the property,am exclusively contracting with-0keneed PERMIT ISSUANCE contractors to construct the project(Sec.7054 Business and Professions Code: a� The Contractor's License Law does not apply to an owner of property who 4ALTER-DRAIN&VENT-WATER(EA) builds or Improves thereon, and who contracts for such pkujeds with s aFEE SUMMARY bactor(s)Bernard pursuant to the Contractor's Limns.Law. BACK PLOW PROTECT.DEVICE I_J I am exempt under Sec. B&P C for this reactors DRAINS PLODS.ROOF,AREA,GOND. SANITARY Y N • Owner AN CO.Li EC 2 RECF= WOR SAN COMPENSATION DECLARATION FIXTURES.PER.TRAP d SCHOOL TAX Y_ N_ 01 hereby affirm that I have olesuracertificate of consent m op thereof or D• D RECEIPT N 3800,coniab ofWorken'Comperwtlmnlrauran¢oracertllkd copythenrol(Sec. GAS EA.SYSTEM-1 INC4 OUTLE15 PARK FEE Y N 3800,Lab C.) ED- GAS EA.SYSTEM-OOVER REND Us ' �Cy BUILDING DI V ISION FEES ertiON copy Is hereby furnished. GREASEANDUSTRL WASE INTERCEPTOR PLANCHECK FEE ❑Cenlfled copy Is BIN withh the city Inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date RCCCI t# (Thls.calm,need sea be completed If the permit Is f¢one hundred dollen (Sl(NDdWATER HEATER W/VENT/ELECTR ENERGYFEE Y N Ieertifylfythat In the performance of the work forwhldh this permit is issued, - - I shall not employ any person In any manner so as to become subbed to the WATER SYSTEM/TREATING Workers'Compensation Laws of California.Date PAID O Z Applicant I NEWRFSIDENTIALPLMB. SD.Ff. Date Recei t# Z Q NOTICE TO APPLICANT.-If,after making this CertBlcam of Fxemptlon,you 1: should become sub)ed to the Workros Compevalion provisions ofthe Labor TOTAL: CC N Code,you mu at forthwith comply with such proWime,or this permit hall be -BUILDING E LU 7 deemed revoked. eed. _ CONSTRUCTION LINDING AGENCY SEISMIC FEE CL Ihercby.Mrm that there is a construction lending agency forthe perform ELECTRIC FEE 7 Z anco of the workfor which this perridt Is Issued(Sec.3097,Civ.C.) TOTAL: rBo 00 lerdre.Name PLUMBING FEE bil LL-I- Ireaerb Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE U l cert lfy that l have read this application and state that the above information O W IsmrnetIxgreetocomply wlthaBcity and countyordinanmand gate laws PERMIT ISSUANCE �Sdb FEES PAID: } 1 renting to building ronstrualmn,and hereby authorire repreaentstives ofthla I-. Z city to enter upon the above-meNlonN property for inspection purposes. ALTMORADDTOMFCH. t Me)agree to save,Intl emnlfy an d Exp harmless the City of Cu portion Date Receipt# V against liabilities,judgments,code a rad ex which may in an seems AIR HANDLING UNIT 10,000 CEM) Ba antYs r any SUBTOTAL: against City In consequence of the granting of this pemnit. AIRHANDWNGUNIT(OVER 10,1100CIII CONSTRUCTION TAX Sig./re of Applle t/ oneractmi Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZA RDOUS MATER IALS DISCLOSUR E Will the a pplica nt or lower building occupant store or handle hazardous HFATINGUMT(TO 100,000 BTU) Date- Recei t# r 'mum,lal as dcfi red by,the Cupertino Municipal Code,Chapter 9,12,and the �O health and Safety Cod Sedlon 25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL: ❑Yes No Wllltheapplicanto No building occupant use equipment or devices VENTILATION PAN(SINGLE RFSID) ; ISSUANCE DATE which emit harardouaalrcontaminants..defined by the Bay Area Air ' q Quality Management District? BOILER-COMP(3HP OR 100,000 BTI, P,M r D 4Yea ❑No haveradthe huardousmaterials mqutorments under Cha pher6.95of f10ILER-COMP(OVER100p00BTU) ' the California Health&Safety CNe,Sediaa25505,25533and2S534. I _ JUL �n �[I(]7 undentandthatlfthebuildingdoesnmmrrentlyhaveatenant,thalitlsmy NEW RESIDENTIAL MECLL SQ.FN T. x7+72 raponsibllity to notify the omapant of the requirements which must be met ' prior to Issuance of a Certificate mf Occupancy. CiTY'Ut CUFcruu+v Owner or authorlud agent Date TOTAL:I ISSUEDBY:_4.4,2NkNrC4 OFFICE COPY