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22570 APPLICANT TO FILL IN INFORMATION WITHIN,RED LINES — USE BALL POINT PEN ONLY ' Buildingoti Project Identiflon - PERMITNO. 'aaa���a r BuOd o Address: '/'/2255 O �' C sine: ane: /v CITY OF CUPERTINO-BUILDING DIVISION', f�l�_ /D C11 c Name:'i 55 ua.No APPLICATION'/PERMIT LJ zY 1I G BU[LDING-ELECTRICALPLUMBINGMECFIANICAL CATEGORY CONTROL X Archlteci/Engineer. - Lt.Nce ' QTY ELECTRIC PERMIT FEE. BUILDING PERMIT INFO Address:. `' POWTISSUANCE ❑ I� LICENSED CONTRACTOR'S DECLARATION IfC� I hereby affirm that l an,licensed under provisions of Chapter 9(commeno APPLIANCES-RESIDENTIAL " JOB DESCRIPTION Ingwith Se on7000)of Divisim3afthe Busimmand PmfesslonsCode,and my - - lknow is in full farce and effect. PANELS License Class 'LICX Dale Contractor ARCHITECT'S DECLARATION 201-10DOAMPS qZ I understand my plans hall be used as public records. OVER I(DO AM79 SQ.FI.FLOOR AREA S/SQ.FT. . q��++ °C �.L E D .I N`. 6i 0 is Licensed Professional SIGNS ELECTRICAL - - tt'�-tL0'1 OWNER-BUILDER DECLARATION SPECiALCIRCUIT/MLSC ' '^ �.., I herebyaffirn that l am exempt fremthe Contraeorb License Law for the C6•/ TER, fallowing reason.(Section 7031.5,Business and Professions Code:Any city or TEy,P,METERORPOLE INST. ' DAM xaaassaaaasaaass�ssa �, countywhich requirma perndttemnstrur,alter,improve,demolbh,orrepalr �� W 6/ - a anystmu mprior Wiblmame,alwrequirestheapplcantfoi'euchpermitto POWER DEVICES 'c�1JJ f C T V file a signed statement that he b licensed pursuant to the provisions of the 3:8 CoMram.en License Low(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC . VALUATION {.. O si6n3ofthe Businnsand Profemiom Code)orthathebexempttherefromand - �y�0 Y13 the basis for the alleged exemption. Any violation of Section 7MI.5 by any OUTLETS-SWITCHESFIXTURES applicant fora permit subjects the applicant to a civil penny ed not nnrethan five dreddollam($500). NEW RESIDENTIAL ELECTR - SQFT. STORIES TYPE CONSTRUCTION 7 e owner of the property,or my employees with wag"as their sole c pensation,willdothework andthestrir misnotinlendedoroffered(or Ole(Sec.7094 Business and Professbm Code:The Contractors License Law r�$ durance applytoan owmro(propertywho bulldsor Improvestherem,and who doessuchwork him " selforthrough hisownemploye ,provided thatsuch ' OCC.GROUP RES,UNITS q Improvements are not Intended aroffered forsale.If,however,thebulldinger TOTAL: - n/�/ Improvementbsoldwlthln omyearofcompletion,theowner-bulderwBlhave tbg burden of proving that he did not bund or improve for purpose ofsals.). QTY. PLUMBING PERMIT FEE FLOODTDNE APN M I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE - } contractors to contmet the project(Seo 7046 Business and Profession Cade: , �J The Contrador.License Law does not apply to an owner of property who { Wilds or improves thereon,and who contracts for such p(ojects with a ALTER-DRAIN&VENT WATER(EA) I ctor(s)Bernard pursuant tothe Contraor's License Law. FEE SUMMARY ctam exempt under,Sec B&P C for this reason �c�FLOW PROTECT.DEVICE 151 - OUTSIDE FEES DRAINSFLOORROOF,AREA,COND. SANITARY Y_ N Omer Date RECEI'T X 'f WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP, SCHOOL TAX Y_ N ❑I hereby affirm that I have a certificate of mnent to self-ineurs.ora J EpT N mAifimteofWorkera•Compenali=Insuranmara"etifledmpythereof(Bec. GAS EA.SYSTEM-IINCAOUTLETS PARK FEE Y N_ I. 3800,Lab C.) - Policy X - RECEIPT X Cum any - - GAS FA.SYST M-OVER4(EA) .BUILDING DIVISION FEES Certified copy is hereby fuMshed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE' - ' FICertiffed copy is filed with the city Inspection division. ` _ 1 . CERTIFICATEOFFXEMPTION FROM WORKERS' . GREASE TRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 20081• Date Recei& (Thio se[Ien need not be completed if the permit boron hundred dollars (Sl D3)mfWATER HEATER W/VENT/E.ECTR ENERGY FEE �Y_ N_ ' Icertifyththat Mthe per(amance a(thewmkforwhich this permit Is blued, 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 Applicant Date Rch ei tN Z Z NOTICE TO APPLICANT;If,after making this Certificate.f Exemption,you NEWRFSIDEMHALPIMB. SQFI. Qshould become subject to the Workers'Compensation provision ofthe Labor TOTAL: N' Code,you=at forthwith comply with such provlslons orthiI permit shall be B G •E s jdeemed revoked. W — CONSTRUCTION LENDING AGENCY SEISMIC FEE ' CL Iherebya(firm that there Is comminution lending agency for the perform TOTAL: ELECTRIC FEE M Z ance of the work for which this permit b Issued(See.3097,Civ.C.) - (.) 2 ]enders Name 'PLUMBING FEE LL !- U.der.Addresa - - QTY, MECHANICAL PERMIT FEE MECHANICAL FEE OW Icertifythat I have readthb eppllmtionand rtatethatthe above information - C Iscorrect.I agree tocomply with all city and munly ordinances and stare laws PERMIT ISSUANCE '-CD FEES PAID: ' N relating to building contraction,and hereby authorize representatives of this .(_ Z city to enter upon the above-mentlomd property for inspection purposes.. ALTER ORADDTO MECH. , (We)agree to save,indemnify an d keep harrniew the City of Cupertlm - DRte Receipt# V against lbblll les,jud menta, d expeasea which may In any way accrue AIR HANDLING UNIT(TO IO,ODO CFM) SUBTOTAL:- agalra Id in n the grastlogoithl permit. AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX re o(AppBran[/ . ra r Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HA OU MATE LSDI LOSURE 1l the applicant or future building ocev ore or handle hazardous• IIFATINC UNIT(TO BTU) �Cb Date Recei tri material as defined by the Cupertino Municipal Code,Chapter 9.12,and the limltharxl Safety Code Smile.25532(.)7, HEATING UNIT(OVER 100,D00 BTUI - ",TOTAL: Yee - I]No VEN'fIIATION FAN RESID) TVIV the applicant or future bcllding rampant use equipment or devices -ISSUANCE DATE which Pict hazardous air contaminants as defired by the Bay Area Air -- ggiYpp ppppaa�� 1; Ilty Management Dls N. - BOILER-COMP(3FQPOR 100,000 BTU) a P'4'ilTl`,s11 Yes LIr'U7 No have read lM1ehazar�ous materia.requlrementsunderChapter 6.95 of BOILER-COMP(OVER 100,000 BTU) . - theCalifornbHealth&Safety Code,Sections 25505,25533 and25534.11111( understand that ifthe building-do"not currently have atenant,that ltismy NEW RESIDENTIAL MECHAUG . SQ.FI responsibility to notify the occupant of the requirements which moat be met ' - priortoissuance of a Certificate of Occupancy. _ /y/aa per , - ' Owner or authorized agent Data, te. � - ISSUED BY; - OFFICE COPY v