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24257 APPLICANT'TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Prv'ca Identification - PELWTN24257 , 4 2 5 7 Building Address: Z 1� 12 _ C ���1V rnem: V L� r bonen s A CITY OF CUPERTINC BUILDING DIVISION q c naso Mame: Lie.No: APPLICATION I PERMIT — 2 O �s v BUILDINr- LE RICAT.MUMBINGM FC NICAL CA CATEGORY CONTROL9 A tea/Engineer. Lie.No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO ' Address: - LICENSED CONTRACTOR'S DECLARATION PERhIITISSUANCE El 1:1 ❑ I hereby oirmthatlaiv Bconwd under eBuW mandP fChapter9de,and c APP11ANCESRESIDENffAL JOB DFSCKE'IION Ingwllh Sete d1fQr)a ddfeon3ofthe^B7usl7neCu-a-nfd1Pro(esalonsCode,and my License(Cls fu8 rc�andLle.N / J V "7 r PANELS$in (� Date an 47- Contracter LIP TO 200AMPq W ARCHITECTS DECLARATION 201-1000 AMPS gg ZpClundemtandmyplanashaBbeueedaspublicremrds. OVERIOBBAMPS SQ.FF.FLOOR AREA $/SQ.FT. E�tj Licensed Professional SIGNS ELECTRICAL rx nm WG�6 E OWNER-BUILDER DECLARATION SPECIALCERCUIT/MIST / \' '"! owing rasormthaton 7031 ,8 from theossa Contractors Codcicense Law fort he U Zq following reason. i alanr WtwB is Business Professions Code:Mycity it 1 62-[y c°untywhich requirnapermit to constroa,alter,bnprove,demolish,orrepalr TEMP.METER CREOLE INS?. 7 anystma mprlortoltsbwance,alwmquimatheappllcantforsuchperMttmo J ruE file a signed statement id t that he ls licensed pursuant to the provers of the POWER DEVICES O�fn Contractor's License Lan,(Chapmr9(co.enting with5ection 9000)of OfvI- DA Non 3 of the Be° usinsand ProfenlonsCode)or that he ls exempt therefrom and SWIMMING IDOL ELECTRIC A �q the basis for the alleged exemption. Any violation of Section 90315 by any Q V G applicant mra permit subjects the applicant to a civil penalty of not rrorc than OUTLETSSWITCHESFIX7URES co -VV dre eve 1,as nerofthepr. NEW RESIDENTIAL ELECTR SQ.1rr. STORIFS TYPE CONSTRUCTION �n ❑I,as owner of the property,or he employees with wages their dole compensation,will Buss e s ahe work des m atr odure Isnot Intended or coffered for O sale(Sec.7044,Business and Profeislors Code:The Contraaole License Law S$'Q does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP° RES.UNITS whodoessuchworklumaeiforthrough hisewnempioyees,providecithatsuch Improvements arenot Intended oroffered for sale.If,however thebulldingor TOTAL: Improvement®sold within.neyearofcompletlog the owner-W Bderwill have t ` krden of proving that he did not build orimprove forpurposeoale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE ..trade.to construct the project(Sec.9044,Business and Professions Code: The Commetor's License Law does not apply to an owner of property who ALTER-DRAIN&VEM-WATER Wilds or improved thereon,and who contracts for such pWjeaa with a MAI cgnt{actor(c)licensed pursuant to the Contractor's License Law. FEE SUMMARY LJ I am exempt under Sec. B &P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N . Dare RECEIPT It WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N ❑I hereby affirm that I have o [esu ate of consent to opytherso ora RECEE'1.N 3800,1.eofWorken'Compensatlonlnsurantt orattrti(kd ropythereot(Sec. GAS EA.SYSTEM-1 INCAOUTLETS 3800,Lab C.I PARK FEE Y— N— Policy q RECEDING Df N Com any CAS EA.SYSTEM-0VERd(FA) BUILDING DIVISION FEES ❑pC.hiied copy ls herebyfurnished.the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE ❑Gartered copy V filed with the sty Inspection division. CERTIFICATE OF h](EMPEION FROM WORKERS' GREASETRAP PAID COMPENSATION INSURANCE SEWER-SANITARYSTORM EA 200FT Date Recef t# (Thlsloss.) need notbe completedi(the permit ls(Drone hundred dollars ($1 Immless.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N Imrtify that In thep;=ntt the work torwhich this permit is issued, — I shall nme mploy any racoon In t4,manner so a to WATER SYSI.FA7/.I.RFA.I.ING PAID Workem'Gontp nsulem Laws a]Iternla. DaOa-D Q Z App�lcadt NEW RESIDENTIALPLMB. SQFT. Date Recei t# Z Q NOTICE�T PLICANT: aft r.kriog this CertlficateofF creption,you sheuld become subject to the Workers'Compensation provisions of the Labor TOTAL: = �) Code,you mu at forthwith comply with such Provisoes or this permit hallM LU > deemed revoked. FEE BUILD NG O CONSTRUCTION'LENDING AGENCY SEISMIC FEE T Iherebyafflrmthat there is a commaction lending agency forthe perform, TOTAL: ELECTRIC FEE M O ante of the work!or which this permit is issued(Sec.3097,Civ.C.) - U _ Lender's Name PLUMBING FEE LL H Lender's Address QTY. MECHANICAL PERMIT FEE . MECHANICAL FEB O W 1orrtity that have read this application and Nate that the above Information 1 lsmurea.lagreetocomplywithallcityand county ordinances and Nate laws PERMIT ISSUANCE FEES PAID: W relating to building construction,and hereby auHifiHzd�mpreaentativea ofthls H Z citymenteruponthe above-mentb`ned property Porins cion purposes. ALTER OR ADD TO MECH. Date ROfeip[# _ (We)agree to save,Ind hinny an d keep harmieas t e City of Cupedlno againsthabllitles,pdgme ts,co&sandexpenseswhlch� ylnanywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) - SUBTOTAL' aga Inst said Clty in cones mnceofthegranting ftht rout. C AIR HANDLING UNIT(OVER 10,000 CEM) CONSTRUCTION TAX S reef AppRat ontraaor Dae EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PA ID: H RDOUS MATERIALS DISCLOSURE - Wllltheapplicantorfuturebuilding occupantstoreorhand iehazardous HEATING UNIT(TD 100,000 BTU) Date Recei [# material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Healthand Safrty Codion 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: ❑ Yea No Will the applicant future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISS A TE which emit hazardous air contaminants as defined by the Bay Area Air .� Qu a llty Management Di�sAtract? BOILER-COMP DHP OR 100,000 BTU) . Y" ®1V�r.".° 2 3 1992 have read thehazarpous materials requirements under Chapter 6.95 of BOILER-COMP 100,000 BTU) SEP the California Health&Sat"Code,Sections Z505,25533 and 25534. I understand that lithe buedfng does not currently have a tenant,that it is my NEWRESIDENTIALMECH. SQ.FT CIIY Ur lrurrriI h4u responsibilitytonotifytgeoccupantofAh.xe irementawhichmustbemet .prlortolssuarmofa 'rtlf at Occupancy. (3 i-� q �? "C 7 Owner or authorise a nt Data TOTAL: ISSUED BV: OFFICE COPY