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22641 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY co Building Pm ca Identification PERMITNO. tlullding Addrer: 22641 m s ante. n A CITY OF CUPERTINO-BUILDING DIVISION tractor's ante: LIc,Nm APPLICATION /PERMIT , BUfLDINGELECTRICAI.PLUMBINGMECHANICAL CATEGORY CONIR .X/` /t T Arch set/Engineer. Lic N. V� cUV QTY ELECTRICPERM/T FEE BUILDING PERMIT INFO Address: I'FTttATI55IlANCE � I� X ❑ LICENSED CONTRACTOR'S DECLARATION �Q� I hereby ection mthat Diviol am ..Riseunder Busi bldPmfeWonr9de,and c APPLIANCESRESIDEM'fAL JOB DESCRIP170N It-1 t.wf000)of Divldm3ofthe Buelnmand ProferlonsCode,and my L 'e, In(salt and d(ect. PANELS License r Lk.N Date ContractorUPT02DO AMEM ARCHITECTS DECLARATI 201-IfDO AMPS - , ce0 Z I understand my plan sisal be used r public s OVER 1000 AMPS SQ.FI.FLOOR AREA $/9Q.FC. aOCO Licensed Pnefmional SIGNSELECTRICAL f too 4 ax3$ 6 Fkgo OWNER-BUILDER DECLARATION `�,�J l In SPECIALCItCU1T/MISC �y 09- owingrIhembyaffimthatlam31.5,Business fro and ntracturesCode: aw roethe �j —1 Foo countyw rceson.uncapction rmittoommuct and Professions Code:Mycity it Z"� ]EMP.METER OR POLE INST. � county which tcqulrnapertNtromrutmct,alter,Impmve,dennWh,orrepalr, q any structure prior to its Issuance,also requires the applicant for such permit to POWER DEVICES [5 O file a signed statement that he is licensed pursuant to the provisions of the PW1 Contractors License Law(Chapter 9(mmmenirg with Section 7D0()of Diel. SWIhpgNG POOL ELECTRIC VALUATION�s eon3ofthe Budnessand Profmlom Code)orthathebemmptthemfmmand 6 the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWIT'CHESFLXT URES / � a o applicant lore permit subjects the apphcanttoa civil penalty of not more than flv�undred dollen($SOO). NEWRESIDENTIALELECTR SQ.FT. E$ TTyyPP�[ O STRl1CT10N �n is a owner of the property,or h. employees with wages r thele sole s /E C 1 crnpsnrtion,B.doethework.and thestmau71 is henot Cotractodor offeredLaw H C O don Sec.apply to anow arWProfmlov who Wild,C improvens Lt.hervee Law $$ dao net suchoan owner of property whebu mpoymprovothereoRand who does tints am khimaen ed roughedor employees,how,providedthatsuch Improvementsarenot intended earofco forole.1[however, gder l lI have T'Tmef Improvement bwld within he rust completromprove for purpose of sale.). have llg;-kur as o neerprovingof the pr eeW na excluild usively improve ting with livens. QTY. PLUMBING PERMIT FEE Ltr[as mucor tr the property,em exclusively Business and with ns Coed PERMIT ISSUANCE TheconCo ors to consimnsect Law ject does ec.nor appy to nt owner of pro ons Code: % W The Contractor's License Law don cart apply ct an owner a Property who o"p.tbuilds.or Improve thereon,and who contracts for such p[ojecb with a ALTER-DRAIN VEM-WATER(EeU cp_jLa exempt pursuant to the Contractors License Law. FEE SUMMARY LJ I am exempt under Sec B &P C for this reason BACK FLAW PROTECT.DEVICEOUTSIDFFFrS DRNNS FLOOR ROOP,AREA,COND. SANITARY Y N Owner Date RECEIPT M WOR KMAN COMPENSATION DECLARATION FD(Tl1RES PER TRAP SCHOOLTAX Y_ N C31hereby affirm that I have a certificate of consent to self-Insure,or a RECEIPT N certificate ofWorkera'Compensation lveueence or a certified copy thereof(Sec. GAS EA.SYSTEM-1 A'CAOUTLEfS �� PARK FEE - Y_ N_ 3800,t bC.) RECEIPT'N PolicyN GAS EA.SYS W' OVER 4(EA) BUIL DING DIVISION FEES COm ny Certified copy b herebyfurnished.the city GREASE/INDUSIRL WASTE INTERCEPTOR PI"ANCHECICFEE Certified copy b tiled with the city IvpecHan division. Y� a. CERTIFICATE OF MEMPTION FROM WORKERS' GREASETRAP PAID���' (•� a--/'^� COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 20017 Date Recef Iq :Jo• / (This section need net be completed If the permit Is forone hundred dollars ($10(i)or leo') WATER HEATER W/VENT/EL[CTR ENERGY FEE Y_ N_ I certifythet In the performanceof the work for which this permit Is boated, I shall na employ y eraon U t) mance n� marc d to the WA•I.PR SYS)FM/.IREA•DNG - PAID Workers'C v we to L(i O Z Applicant NEW RESIDENTIALPLMB._SQbT. Date Rewe tN Z hOlICE TO PLICANT:It,after raking lis erti Vole of Faemptbn,you should becomesubject ro the Workers'Cem allot provisions of the Labor . TOTAL: N Code,you must forthwith comply with such provisions orthb permit shall be BUILDING FEE W j deemM revoked. CONSTRUCEION,LENDING AGENCY SEISMIC FEE IL Iherebya(flrmthat there b a comtructlon lending agency for the perform- TOT ELECTRIC FEE D Z ance of the workfor which this permit is Issued(Sec.3097,Civ.C.) 1. 02 Lenders Name PLUMBING FEE LL F Lenders Add. QTY.I MECHANICAL PERMIT FEE MECHANICAL FEE N O I cerdfythat I have read thbapplloilun and statethatthe above Information W Is correct.I agree to comply with all city and county ordinance and nate laws PERMITISSUANCE FEES PAID: CL } N relating to building construction,and hereby authorize representatives of this - _. f. Z city to enter upon the above-mentioned property fee bapectiun purposes. ALTEROR ADD TO MECH. Date ROceiptlf (We)agree to save,Indemnify an d keep harmlm the City of Cu pert Ino V egaNat it blI ,pdgmenb,cortaandexpenseswhichmayinanywayacaue AIR HANDLING(INR ITO 10,000 CFM) SUBTOTAL: .gal d It consequence of ant this permit. AIR HANDLING UNIT(OVER 10,000 CTTT) CONSTRUCTION TAX S .turemAppOcant/Contndar Date D(HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HA2ARDOUSMAT LSDISCL SURE Will the applicant or future buildingo ntatore rhandlehazardom HEATING UNIT CFO 100,OW BTU) Date ReceI tN material as defined by the Cupertino MuNdpal GC apt.r9.IZa.dthe Health and Safety Cade Section 25532(.)7 HEATING UNIT(OVER 100,00(l BTI) TOTAL: qYes No llltheapplimntor mmbruildingampantusecquipmentordevico VENTILATION PAN(SINGLE RESID) ISSUANCE DATE whichemit hazardous air contaminantsas defined bythe Bay Area Air PAID Qu Illy Management District? P 7 BOILER-COMPDHP OR100,0(DBTU) AID QYo F1 No Rha .read the h.Vus materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTI) ee} the California Health&Safety Code,Sed love 25505,25533 and 25536.I c� unit ersta nd that if the W lld Ing does not currently have a tenant,that It b my NEW RESIDENTTAL MECH. SQ.FT. rrpomibWty to ofa the part oft he rnprirementswhich must be met pdortotame bady to nosy the to o(toftheOcou pa nay. Owner or authorized agent DateTOTAL: ISSUED g . C OFFICE COPY '