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22791 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Pru ece Identification 7777 PERM NO. Building Address: 22791 1©59 2 LL i mer 263— . oo CITY OF CUPERTINO-BUILDING DIVISION O G Ce tra ore Nam: .N : APPLICATION I PERMIT 1� .' Architect/Engineer. Lk.No: BUILDING-ELECTMCALML BING-MECHANICAL CATEGORY CONTROL X QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO Add.. ®LICENSED CONTRACTOR'S DECLARATION PERMITISSUANCE 1:1 El 1:1 I hereby affirm that l nn licensed under provisions of Chapter 9(commrnc APPLIANCESRESIDENITAL JOB DESCRIPTION Inense Is in fon force of Dl affect fthe Businemand Pm(essionsCode,and rtry license la in s (ores and erten. PANELS , License Class Lk.X w Date Contractor LM IQ 200AHM ARCHITECPS DECLARATION 201-1000 AMPS p 2. I understand my plane shall be used m public records. OVER 1000 AMPS .SQ, lb $/SQ.FT. Licensed Professional SIGNS ELECTRICAL „ TERJ 6 OWNER-BUILDER DECLARATION SPFiCIALCIRCUIT/MLSC U\J II Z�.., a I hrmbyafgrmthat l am exempt from the Contractor's Llmnse Law for the pp (ogog reason.(Section 7831.5, ess Businand Professions Code:Anyty or l OZ win , NST. /0//0 Fhiche ap uwn,atpoedemlbh, r r TEMP.ME ERORPOLEI anystm ptoihaameatsaregWrtheaet ett file a signed statemnt that heis licensed pursuant to the provislose,of the POWER DEVICES Commences License Law(Cha pier 9(ecmmendngwith Section 7000)o(Dlvl- / l Divi- SWIMMING POOL ELECTRIC son3oftheBunssndProfewiomCoe)orthat helaexempttherefromand VALUATION the basis for the alleged exemption. Any violation of Section 70.71.5 by any /s applicant fora perotsubje00)natheapplicantioa civil pewltyof net morethan OUTLETS-SWITCHES-FIXTURES f� OOO Vd five hundred dollars($5 . a �n ❑1,as owner of the property, NEW RESIDENTIAL ELECIR SQ.FT. STORIES TYPE CONSTRUCTION p party,or my employees with wages thele sole C compensation,will do the Business andweak and thes Codrrebn t intendedContractor or kens Law 5�O site(Sec.7644,Business and Pmfevbre Cade:The Contractors License law doea not apply to an owner ofproperty who builds or improves thereon,and OCC GROUIa RES.UNITS whodomsuch w°rkMmself orthrough hisownemployeea,provided thats ch Improvements are not intended oroffered forests.If,however,thebullding or TOTAL: Improvementbe ldwithinoneyrarofcompiniogtheowner-bugderwillhave ;Nan of proving that he did not baud or Improve for purpose orale.). QTY. PLUMBING PERMIT FEE FLOOD ZANE APN (��1 owner of the property,am exclusively contracting with 1loensed ontractore to construct the pmjen(Sec.70JA Business and Professions Code: PERMIT ISSUANCE The Contractor's License law does not apply to an owner of property who ALTER-DRAIN&VFM-WATER(EA) builds or Improves thereon,and who cottram for such projects with a If gqlllltt��actefts)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY xl_j I am exempt under Sec B&P C for thio reason DRAINS.FLOG R SANITARY Y— N OUTSIDE FFr4'— Owner Date R ROOF, GOND. WORKMAN COMPENSATION DECLARATION RECEIPT#SCI{ODL ❑1 hereby affkm that I have a o:rtmMTURES PER'IRAP Ncate of consent to elf-home,of TAX Y N_RECEIPT Y 3800,lLab CJ AS EA. ofWorkere Compewtlonlnsuranre ora ttrtl(kd copytherco(($ec. G .SYSTEM-1 INCd OUTLETS PARR FEE Y N 3800,l Poll Y Com ny GAFA.SYSTEM-OVER 6(EA) RECEIPT M CS Certified copy is hereby furnished. BUI LDINC DI VISION FEES E]Certified copy u filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID COMPENSATION INSURANCE (I'hlesetuonneed not beurnpined lithe permit leforomhundred dollars SEWER-SANITARY-STORM EA.200171", Date Recei t# (E100 Imnifyify that lathe perfommnm of the work for which this permit is lYsved, WATER HEATM W/VENT/E,ECTR ENERGY FEE Y — N I shall not employ any person in any manner w as to become abject to the workcn;Compensation Laws of California.Date PAID SYSTEM/TREATING Q Z Applicant Z O NOTICE TO APPLICANT:101m,making this Certlicateof Exemption,you NEWRFSIDENTIAL"ll. SQ}T. Date Regi t# Pshould become subject to the Workere'Compewtfon provtsiom of the Labor TOTAL: WN Code,you most forthwith comply with such pvisioar this permit ahall he rons> deamed revokes. BUILDING FEE IL o CONSTRUCTION LENDING AGENCY SEISMIC FEE _ 1 hereby of lrmthat there b a construction lending agency for the perform- OZ ante ofthe work forwhich this permit Is Issued(Sec.3097,Civ.CJ TOTAL: ELECTRIC FEE L) Larder'.Name PLUMBING FEE LL 0 l.cnaer§AQTY. MECHANICAL PERMIT PEE O W Irertityththatl atl have read this application and alatethattheabovelnformatlon MECHANICAL FEE (L bcorrect.I agreeto comply with all city and county ordinances and date laws PERMIT ISSUANCE FEES PAID: } N relating tobullding construction,and hereby authorize representatives ofthb H Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. — (WO agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt# against liabNties,judgments,amassed expenses which may in anywsyscum AIR HANDLING UNIT(To 10,000 CFM) SUBTOTAL, agaketsaid Ci tsconsequen fine anon thispemNt. AIR HANDLING UNIT(OVER 10p00CFM) CONSTRUCTION TAX sig rant n er Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARD UB MATERIALS DISCLOSURE Witthcapplicant or folum building occupant sterner handle hazudoua HEATING UNIT(TO 100,000 BTU) _ Date RCCCI muterial as defined by the Cupertino Municipal Code,Chapter 9.1$and the t# Health and Safely Code Section25532(a)7 HEATING UNIT(OVER 100,000 BU) TOTAL. Q ❑Ye MN. Will the applicant en future building occupant use equipment or devims VENTILATION FAN(SINGLE RESID) ISSUANCE DATE which emit haaardoua air cents Mmnts as defined by the Bay Area At, Coqq Quality Mawgement District] BOILER-COMP OHPOR 1OQ000 Yes ❑❑No havereadthehazardo.s.tedabrequirementsu.des Chapter6.95.f BOILER-COMP(OVER 100,OW BTU) the Califorole Health&Safety Code,Sections 25505,25573 and 25534.1unders reePmmndthat notifythe the n building does not errently equire ave encs which that it out NEW RESIDENTIAL MECH. SQ.FT nsponsibsi ne of a notifytheof O (t he requirements which must be neat prior to Issuance of a Certificate of Ocavpanry. (jj)1RY Owner or authorized agent pate TOTAL, ISSUED BY OFFICE COPY