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22394 APPLICANT TO FILL IN INFORMATION WITHIN RED LIIJES — USE BALL POINT PEN ONLY Building Praect Identification PERMIT NO. Build lag Add moa: 22394 Lha ti Owners ante: p one: p CI —35 / CITY OF CUPERTINO-BUILDING DIVISION °^tra °:•Nam°:` 1 /J Lie.N.: APPLICATION / PERMIT — S- 37501 BUILDINGELFLTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL M Architect/Engineer. Lie.No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: PERMBTISSUANCE ❑ ❑ LICENB ED CONTRACTOR'S DECLARATION IherebyaBUm[hall am Licm¢ftheunder Buimmand of Chains ode,an me APPLIANCFSRESIDENML JOB DESCRII'I ION IngwehSot n7000)oll effect 3oflhs 8uslneesand Pro(esslonsCode,and my - - Licat Motu o d effect V 3 G PANELS r.LI �.J����```��'///��� Lice Contractor J O7.' ✓T Date Contractor 2011000AMPS ARCHITECPS DECLARATION �qq�uu 00 O I understand my phm,hail be used as co public temde. OVER 1000 AMPB SQ.D i S/SQ. Ff. E Llcemed Professionsl SIGNSELECTRICAL E <�6 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/M19C UTE R 7(..2F, therebyafflrmthatlamexemptfromth°C..t.dor'.Li¢nxLawforthe following reason.(Sectlon 7031S,Business and Prof salons Code:My city or O TEMP.METERORPOLEINST. J, countywhich requlma permit torrogmae,alter,Improve,demolhh,or repair I/�/� W8a any etrecturt prlorrolbls•uance,also requlreslheappllcant for such pertNtla POWER DEVICES !/' F� U file a signed statement that he h licensed purmant to the provisions of the ,y I 3u Contractor'sIAcerue Law(ChepterI(coarmocing with Sectio.MW)of Divi- VALUATION SOS Mona ofthe Business and Professlom Code).,that he 1.exempt therefrom and SWIM IDOL ELECTRIC 6 5 the bash for the alleged exemption. Any violation of Section 7031S by any OUTLETSSWITCHFSFIXTURES O appbontfare permit subjects the applicamtoa civil pemRy.(not morethan ffv�u.dmd dollars($SOO)). NEW RESIDENITAL ELFLTR 1,ea owner of the property,or my employees with wages as their sale e"Q'FT' STORIES TYPECONSTRUCTION compensation,will do the work,and thestmeture Isnot Intended or offered for q .1.(Sec.7044,Business ami Professions Code:The Cmuract.e.License Law $ docs not apply to an owner M preperty who builds or Improves thereon,and OCC.GROUP RFS.UNRS who does such work himself orthrough hlsown employees,provided that such improvements are not Intended orotfered forsale.If,however,the W ilding or TOTAL: improvement h sold within omyearofcomplcti.n,the owner-bulhlerw111 have tle.kurden of proving that he did na Wild or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN u L as owner of the property,am exclusively=trading with licensed PERMIT ISSUANCE commuters to commuct the project(Ser.7044,Business and Professiom Code: The Contractor's License law time nal apply to an owner of property who ALTER-DRAIN&VEM-WATER(EA) builds or Improves thereon,and who contracts for such pIpjacts with a FEE SUMMARY �gp(Tacouits)B¢med pursuant to the Contractor's Limme Law. BACK FLOW PROTECT.DEVICE 1_I I am exempt under Sm B k P C for this remora _ F FVrq DRAINS OR FLOROOF,AREA,COND. SANITARY Y N • Owner RECEBrC F WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOLTAX Y N [-]I hereby at(Irm that I hove•¢rtlflate.f consent to self-insure,ora RECEIPT X camficate°fWorken'Compereatlon Imuran¢or a¢rtBled copy thereof(Sec. GAS EA.SYSTEM-1 INC40UTLM PARK FEE Y N 3800,lab C.) R7217Pf M Policy 8 GAS EA, ST SYEM-OVER 4(EA) Com any BUILDING DIVISION FEES Certified copy Is hereby furnished. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE Certified copy h filed with the city Impection dlvlelon. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCB SEWER-SANITARY-STORM EA 7f10FI Date Recei tIf (TMasectl d COMPENSATION completed N[IIMSURithforone M1undred dollars (slm)arle... ENERGY FEE Y N I¢rti(yt N eperloman¢ofthe work forwhic Ms mdt is4sued, WATER FiFATER W/VENT/©-EC7A — Iehailnate any pants. nner eo to the WATER SYSTEM/TREATING PAID W¢kers'Com tlanla lGIIf ,.Date O Z Applian NEW RESIDENTIAL PLMB. SQFT. Date Reeei tit Z O Nould be IAM: aft rtu ngthbxation pr eo( empUe Labor should becorre subject to the ompensationprevhions of rmit s Labor TOTAL: N Cade,you must forthwith romp h each provisions orthh permit shall be BUILDING FEE LU j deemed revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE ate Ihcmbyaffimthat them h a commuction lending agency for the performm TOTAL ELECTRIC FEE ne Z aeefthe workfor which this permit bIssued(Sec.3097,CIv.C.) V O Ia^der'e Name PLUMBING FEE LL F Lender's Addmse QTY. MECHANICAL PERMIT FEE O W 1rrect' I mAifythatl have readthisapplimtionand statethattheabove information MECHANICAL FEE IL ,co .I agmetocomplywlthallcityand muntyordinanmsand state laws PERMIT ISSUANCE FEES PAID: % relating to Wilding mmtruction,and hereby authorlu mp¢sematives ofthh cir to entero n the above�mentloned for Impaction ALTERORADDTOMECH. F z y(We)agree 1 save,Indemnify an d keep Men the ity of CupertinooDale RecelPt>I V against Liabilities,j,dgme^b,resba^d expenses which may I.anywayecnue AIR HANDLING UNIT(TO 10,"CFM) SUBTOTAL: ' against void City In consequence of the granting of this pennLL - CONSTRUCTION TAX - AIR HANDLING UNIT(OVER 10,000CFM) Signature of Appliam/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will theepplicantorfuture bulldlag occopantsrore.r handle hazard.., HEATING UNIT(TO 100,000 BTU) Date Re el t41 material as defined by the Cupertino Municipal Code,Chapter 934,and the Health and Safety Code Section 7553](x)7 HEATING UNIT(OVER 10,000 BTU) TOTAL: Yea M No Bl the applies I or filum building occupant use equipment or devices VENHIATION FAN(SINGLE RE9ID) Rill DATE which emit haardou,air contaminants as defined by IM Bay Area Air D❑isMct7 _ BOILER-COMP DHPDR 100,000 BTU) • Quality Management 4 Ye, N No J madthehaza ous materials requirements under Chapter 6.95 of IJO1LER-COMP(OVER 100,000 BTU) eC'a" the Ilio izHealthkSafetyCode,Sectlom7550.5,75533and25534.1 ' JUL 5 Xn1detahat lithe Wllding dose nal arrently haveatenanq that lttsmy NEW RESIDENTIAL MECH. SQ.FT.to notitythe t of the requhementsw Ich at be mal,nce ofa Corti to of pan �-a AIA Owner uthod agent JUL. to 15SUEDBY. TOTAL: OFFICE COPY