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23390 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —,USE BALL POINT PEN ONLY Building Protect Identification PERMITNO. Building Address: - 23390 o CT l ween arae: - one: APEA P CITY OF CUPERTINO-BUILDING DIVISION • Contmad sNime: Lhc.Na: APPLICATION / PERMIT L BUR.DING-MECnUCAL.PLUMBINGMECIIAMCAL CATEGORY CONTROL M Archlbut/Englncer• Lic.No: QTY ELECTRICPERMIT FEE "BUILUING PERMIT.INEO. Address: PERMITISSUANCE ICyI ❑ LICENSED CONTRACTOR'S DECLARATION I� Iherebyafflrm that l am licensed ander provWoneof Chapter 9(commenc APPLIANCES-RESIDENIAL - JOB DESCRRrIION Ingwlth5 dion7fl(D)of Divislon3a(the Busimmand Pmfesslone e,andmy �a ; license is in fy�f Ice a�d�9ffeet. ,1, PANELS �r��a'r����{ lar I.Icense Cia;¢ G,'S(Ip.If 3356/y r are" • '- Date-3�,ao�`�—Contractor ^ 201-IMOUP TO200 AWS AMT'S "! —ARCHITECPS DE 1 440 Z I understand my plan shall be used a public records. OVER 1000 AMPS SQ.Fr.FLOOR AREA $/SQ.Fr. O ULicensed Professional SIGNSELECTRICAL 6 OWNER-BUILDER DECLARATION IJn] SPECIAL CIRCUIT/OLE I 71-"vl� lherebyaf rrathat l am exempt from the Contracture License lAw for the oo county Brea equir aperrodon 11.5,Buslnem and Professions Code:h,ormp it TEMP.MEf020R POLE INST. P p county which requlresa permgrocoatmd,alter,lmprove,demolish,orrepalr g any structum prlorto its Issuance,also requlreslheapplicanl forsuch permit to POWER DEVICES l5 O file a signed statement that he b licensed pursuant m the provision of the Qb Contractor's Lici,.Law(Chapter9(mmm rchogwilhSecHon7000)ofDlvl- r" SWIMMING POOL ELECTRIC slon3ofthegueinea and ProfealoaCade)arthat he isexemptthere(romand VALUATION <, the hash,for the alleged exemption. Any violation of Section 7MIS by any OUTLETS-SWITCHES-FIXTURES �� ©� applicant fora permit subjectathe applicant to a dvhl penalty of not more than (f five hundred dollars(1500). I,as owner of the property, NEW RESIDENTIAL ELECTR SQ.FT. RIES TYPE CONSTRUCTION p perty,or my employee with wage as their rale C m compensation,Business awork,andthestrvdurehs Contactor o iceres,Law - 5 O saleface.7ply to an Professions Cods:The or improver Liceael�w p,I $ whodoes t apply loan ownerorthrou hhisty o nem orimpmovidedrthateon,such —and OCC.GROUP RES.UNITS 0.0. wprovemuts arantintwork eldedm atteredowale,IThee,pmvldMildirgor Improvements intended earofcomplelle the nen b deer ldingw TOTA l 11 I Improvement bsold wilhlnoneyearofCompletion,theownerWilderw111 have thILLmaden of proving that he did not build or Improve for purpose ataxic.). QTY. PLUMBINGPERMIT ' FEE - FLOOD TONE MIN Lj Las owner of the property,am excludvely mntradhng with licensed PERMRISSUANCE contractors to construct the project(Sec.7044,Business and Profooloru Code: The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) Wilds or Improve thereon, and who contracts for such pwinds with a cgtdractor(s)licensed prs Ito to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY LJ I am exempt under Sec. B k P C for this maven DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_ Owner Data RECEIPT If WORK MAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N_ ❑I hemby affirm that 1 have o Insumne of consent to opythe cf(Sa RECEMT st 3800,Laeo/Workers'Compevatlan laurance ora certl(kd copythereof l5ec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N Polic If CJ Polley p GAS EA.SYSTEM-OVER 4(FA) RECEIVE ING DI p Cam any BUILDING DIVISION FEES CenlRN copy famished. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECKFEE Cedlfled copy is,filed with the city IapttHon division. CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID COMPENSATION INSURANCE SEWERSANITARYSRJRM EA 70011. Date Recel til (This section need rad bacompleted[(the permit b foronc hundred dollen (S10()orlea3 WATER HEATER W/VENT/ELECTR ENERGY FEE Y N [certify that In the performance o(the work for which this permit bbsued, I shall not employ any person In any manner an as to become subject to the WATER SYSTEM/TREATING Workers'Compensation Laws of California.Date PAID O Z Applicant NEWRFSIDENTIALPLMB. Date Recel t# Z O NOTICETO APPLICANT:If,eller making lib Certificete of Exemption,you c"Q'pT• Fshould become subject to the Workerd Compeneatioa provision of the Labor TOTAL: N Code,you most forthwith comply with such provision or this permit shall be 2 j deemed revoked. _BUILDING FEE s. W — CONSTRUCTION LENDING AGENCY SEISMIC FEE tl I hereby affirmthat there is a mnstrudhon lending agency for the perform- ELECTRIC FEE Z socaofthe work for which this permit is Issued(Sec.3097,Chv.C.) V O I<nders Name 74,1_✓ - PLUMBING FEE LL H Lender's Address a QTY. MECHANICAL PERMIT FEE MECHANICAL FEE OW Icedlfy thaH have mad<hie application and stmethatthe above In formation 1 lawmen,lagreetocomplywithallcityandcountyordlnancesand state laws PERMIT ISSUANCE FEES PAID: relating to building construction,and hereby authodae representatives of this H Z City to enter upon theaWve-mentiomd property for Inspection purposes. ALTER OR ADD TO MECH. (We)agree to save,Indemnify an d keep harmless the City of Cu penin Date Receipt# V against liabilities,to dgments,mks and expenses which may In any way accrue AIR HANDLING UNIT(FEE t 0,000 CFM) SUBTOTAL: against said City in consequence of the granting of this permit. AIR HANDLING UNIT(OVER IQ000CFM) CONSTRUCTION TAX Signature o(Applicenl/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant orfuture building occupant store or handle hanrdous HEATING UNIT(TO t 00,1700 BTU HrAthmaterial as defined by the Cupertino Munlctpal Code,Chapter 9.1 4,and the Date Recei 1 Iicalth and Safety Cod Section 75537(x)7 [iFAT1NC UNIT(OVER 100,000 BTU) TOTAL Ye �No Will the a pplicant or future building ompant use equipment or d evices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE which emit haeardoua Ir mntaminantsascieBoed bylhe Bay Area Air Qu lily Management t' 7 BOILER-COMP QFR'DR IOO,IXq BU[ T 4Yea No havemadthehana ous materials requiregfents under Chapter 6.95 ofBOILER-COMP(OVER 100,000 B'IU) p� the California Health&Safety a e,SMio505,25533 and 25534.1 D understand that if the h doenMmr nttyh.vaatenant,that it is my NEW RFS)DENTAL MECH. SQJ--r reapoam0ltytonoti th mp.stofth gWremente which mu at be met FIAD o n prior to as Rate of Oc rcy. z IWAR `, 1 99z Owner of authm&a agentDate CI/ TOTAL: ISSUEDI V OFFICE COPY