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22640 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PERKING. Bulldin&Addresa: 1 I'� n 0 O G Lt wn rs aameone: CITY OF CUPERT[NOLBUILDING DIVISION 4 c.^tra�taNw. „r•f'f Lie.N. APPLICATION /PERMIT '— 1 br+�0�- BUILDING-MECTRICAL-PLUMBING-MECHANICAL CATEGORY CONTR( Architect/Engineer. Llc.Nce lo(p QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Add. PERMITISSUANCE "�� f-52� LICENSED CONTRACTOR'S DECLARATION Ihereby affirm that l am licensed under provlelonsof Chapter 9(mmmem - APPLIANCES-RESIDENTIAL JOBDESCRI'HON Ingwith Senion7000)o( )ivlelon3ofthe Buslnessand Professions Code,and m license Is In full fora and effect. fj PANELS /�•�� . Limnse Cls® Lic.M Date Contractor UP TO 2DO AMES ARCHITECPS DECLARATION 201-100DAMPS p0.±all e: I understand my plant shall W used s public records. OVER 1ODO AMPS SQ.FT.FLOOR AREA $/SQ.Fr. Eo� Licensed Profestmal SIGNS ELECTRICAL (yl '30. -ku OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC J O lW ' v 7 i„E�h l�8 I hereby affirm that I am exempt(romthe Cool License Law fee the OR .following reason.(9ecd.7031 S,Bushes and Prof.t..s Code:Any dty or .� Q 6�' O Z .METER ORPOLE INST. P4muntywhichrequimapemdwmmtmct,alter,lmpmv demolbh,ormpalr q 6 anystructure pdorto Ila issuance,also requlreatheappheant forsuch permit to POWER DEVICES Nd V Ole a signed statement that he Is licensed pursuant to the provisions of the gn Contrador's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC SOS don 3 of the Business and Professions Code)or that he is exempt therefromand VALUA11ON < the basis for the alleged eedsthea Anyviolation.($cobran0. by any UTLETSSWITCHFSFI;I;ES — V O(• 4C OA appBcantf.ra pemdt aubjectstheappllcent toadvll pevltyanal mom than v 1p J �u veh red dollars($500). NEW RESIDENTIAL ELECTR SQ. I. SIOWFS TYPECONSHRUCTION ea owner of the property,or my employees with wages as their sole c p atlon,w111dolhework,and thestmdure lana Intended or offered for - Ie cors 7My to anowand Pro(mi.s who builds or Improws Ucese law $ docsnotapply torn owner apropertywhobuildsorImprovesthereon,and OCC.GROUP RES.UNITS who messuch mentsa not Intended Nsown e.If, provklhowever, dthat such bnprovemenb are not Intended orof(ered fwsale.IL haweveq thebu0dingw TOT Improvement bsold within one yearo(completlon the cwner-builderwll)have burden of proving that he did not build or Improve for purpose of sale.), QTY. PLUMBING PERMIT FEE I,as owner of the property,am exclusively contracting with licensed FLOOD ZONE "NpQRMR ISSUANCE ! contractors to construct the project(Sec.7044,Business and Professlmu Code: The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN VENT-WATER(EA) - Wilds or Improves themom and who contracts face such pRojem with s r� acto(s)Ocensedpunu tto the ontradm'e License Law. FEE SUMMARY exam sand B k P C for this reason BACK FLOW PROTECT.DEVICE er - `�� Date DRAINS FLOOR ROOF,AREA,COND. SANITARRECY N W IIONAN COMPENSATION DECLARATION QI hereby affirm that I have a cedlOcam of consent to self-Imre,ora ��FIX.NRES I'ER,ISNP $CIiC10L FAX Y RECEIPT N NR mdlflwteufWorkeri Comper donlsumnmoramdNed copythemcf Eam. 1 M,Rab C.7 CAS EA.SYSTEM-1 INCA OUTLETS aaa'• PARK FFP Y N Polley N RECMPT M GAS EA.SYSTEM-OVER 4(EA) Com �Cany - BUILDING DIVISION FEES edifled copy Is herebytM. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE �CedlOed copy la filed withh thethe city Impaction division. CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID (..1} COMPENSATION INSURANCE SEINEWSANITARY-STORM EA 200i•T Date ReCel tit � " (TNsuRlon need cad be completed tithe permit V fwone hundrtd dollars ($100)orless') WATER HEATER w/VENT/EL[CTR ENERGY FEB Y N I certify that in the pedomanm of the wmk forwtdch thlu permit W b®ed, — I shall not employ any person In any manner so s to become subject to the WATER SYSIEN/TREATIN'G Workera Compensation Laws of California. Date PAID SQFr. Date Remi tp '� Applicant Z 0 NOTICE TO MPLICANT:I,after making this Cedlfkate of Exemption,you NLW AE4OENTIAL PLMB. I- Pshould become subject to the Workers'Compensation provisions of the Labor TOT R N Code,you must forthwith comply with such provisions or this permit shall be K 9 deemed revoked. 6UIL G •E W 3 - CONSTRUCTION LENDING AGENCY SEISMIC FEE ll I heroby afOrmthat there b a construction lending agency for the perforce, FEE M Z ance of the work for which this permit Is issued(Sec.3097,Civ.C.) 70 02 Lenders No PLUMBING FEE LL I- I<ndera ndd,ea, QTY. MECHANICAL PERMIT ME MECHANICAL FG OW Ices ltythat l have readthisapplicatlonand watelhatehe above lnformatlon 4 lacorrect."grmlo comply with all city and county.rdinancesandwatelaws PERMIT'ISSUANCE FEES PAID: r relating to building comtrudlon,and hereby authmlme representatives of this (.. Z city to enter upon the above-mentioned property for Impaction purposes. ALTERORADDTOMECH. �� (We)agree to save,Indemnify an d keep harmles the City of Cupeutince Date 'ptH V against llabWtles,Pdgments,cows and expenses which may In any way accrue AIR HANDLING UNIT CFO IO,OW CFM) $UBT AL• agalst sal Incoseque oftbe antinga this perm . _ AIRHANDWNG UNIT(OVER ID,000CFM7 CONSTRUCTION T4 -1 ;gdenatu of Applu C tractor ' Date EXHAUST HOOD(W/DUCT) CONSTRUCTION PAID: DOUS MATERIALS DISCLOSURE _ WBltheappli cat or future building occupant acre orhandleh.,dozes. HEATING UNIT(TO 100,000 BTU) �" Date R i tH trvterialasdefin by the Cupertino Municipal Code,Chapter 9.12,and the - HeNo alth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BM T�•OYen , ilitheappllcant or(urum a•.Ilding occupant use equipment or devices LATION FAN(SINGLE RESID) �— 19S4$0 DATE which emit hazard...an com mduu is as cieOnsd by the Bay Area Air Quality Ma nagemcnt District? BOILER-COMP OHP OR 100,000 BTU) 4Yes �I No , NOY 22 1991 havereadthehaur�ouamatedalamrylremenunnderChaper6.95ot BO LERCOMP(OVERi00,000BTU the California Health A Safety Code,Sections 25505,25573 and 25534.1 understa cad that if the building does not mrmstly have a temriL that it 6 my NEWRFSIDENTIALMECH. SOFT. /� responsibility to notify the occupant of the requirements which most be et Ci'I Y'wt,ouitwfl-INQ prior to Issuance a a Certificate of Occupancy. res ' Owner or authorized agent Date- ISSUED B . lOT OFFICE COPY