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22833 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY - Building Project Identification PERMIT NO. Building Adams: 2 2 8 3 3 weers ams: one: r - , . CITY OF CUPERTINO-BUILDING DIVISION `© Con=s Lic•No: APPLICATION / PERMIT 10— 8 117 • BUILDINGELECTRICALPLUMBINGMMHAMCAL CATEGORY - CON'�Ob/)OQ Arcbliect/Engineer. - LIB No: - Ca L 1 QTY ELECTRIC.PERMIT FEE BUILDING PERMIT INFO mama: ' - • PENITTISSUANCE 1�1 ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION - I_.❑ I hereby affirm that l ace licensed under prwhlonsofChapter9(commme- APPLIANCES-RESIDENITAL ]OB DESCRIPTIONingwlth Sedion7000)o(Division3oflhe Busiaessand ProfeselonsCode,and my - license Is in full form and effect. PANELS Pew �^1Y�1 �y Licene Class LiL.11 • J Date C°ntndor ARCHITECTS DECLARATION 2101.100)AMPS q .SQ.1•T.FLOOR ARFK S/SQ.FT. q��++070. -]understand my plans be used as records. DYER 1030 AMPS Ii Licensed Professional ) SIGNS ELECTRICAL <6 OWNER-BUILDER DECLARATION 1n SPECIALCIRCIRT/M15C ' 2 E. I hereby afftrm ttit I am exempt fromthe Contndorb Llcenee Uwlor the (ollowmg xawn.(Section 70315,Buclnen and Professions Code:My city or \ O TEMP.METER OR POLE INS[. countmmmprequires toJ(si ameamit to onstruct,omqui stheapliuntfrsuch, er ttr - ale atil red stal,,meat lun he e,alsoxqulren suet tolthe pro esions rmlt a POWER DEVICES y'µ file a signed dalemsnt that Es b Ilctnsed pursuant to the proal loss of the Dµ Contractor's License I.w(Chs pier 9(commencing with Section 7000)ofDivi. �OS Blue 3 oft he Business and Profession Code)or that he b exempt therefrom and SWIMMING POOL ELECTRIC _ -VALUATION the bash for the alleged exemption. Any violation of Stolon 70315 by any OI7TLETSSWITCtLESFtXTURFS 04..Vo�F applicant for a perndt subjects the applicant to a civil penalty of no mreathan five hundred dollars(5500). I,as owner of the property, NEWRESDENTIALELECTR SQFI. STORIES 'TYPE CONSTRUCTION �a ❑ p perry,or my employees with wages as their sole 'compensation,willdothe work and thestructure Is not Intended or offered for - M qnae(Sec.7044,Business and Professions Code:The Contractor.License Law does not apply to an owner of property who builds or Improves thereon and OCC GROIJI' RES.UNITS doessuchworkhlmselforthrough hbownemployees,provided thatsuch improvements are not Intended oroffered for sale.If,howevsq thebuili ing or TOTAL: improvement bwld wilhinoneyearo(completon,the owner-bu0derMll have 0W.Ilurden of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD TONE APN "L as owner of the property,am exclusively contracting with Licensed contractrns to construct the pmjed(Sec.70K Business and Profession Code: PERMIT ISSUANCE The Contractor'.License Lew does not apply to an owner of properly who - builds or Improves thereon,Bad who contracts for such pwjKU with a I ALTER-DRAIN&VENT-WATER EEA) mp¢ador(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY Ll I am exempt under Sec B& P C for this rea on BACK FLOW PROTECT.DEVICE DRAINS R FLOOROOF,AREA,COND. SANITARY Y N Owner Date RFOEB'T.s WORKMAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCHOOL TAX Y N- 711 hereby affirm that I have a certificate of consent to self-Insure,ora 11 t RFOFBI'I'a certificate of Workem'Compeountlon Insurance ora certified ropy thereof(Sec. GAS EA.SYSITM-1 INCAOUTLE15 - PARKFEE Y N 3800,lab C) RECEU'T a Toliry N GAS EA.SYSTEM-OVER 4(EA) Cam ny BUILDING DIVISI FEES [Certified copy b hereby his sGREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE - F-1 Certified copy bfiled withth the cityty lnpedlon division. al,al� (�a•�{`"' CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID 1. I4"'�•a COMPENSATION INSURANCE SEVER-SANITARY-STORM EA.200FT. D Retxl t# (Thissection need not be completed if the permit h for one hundred dollars _ (8100)orhn3 WATER HEATER W/VENT/ELECTR ENERGY N I ce.r 1,that In the peAmce ounof the work(orwhlch this permit b issued, I shall not employ any person In any manner w as to become RsbjeL,t°the WATER SYSTEM/TREATINGWorkerB'CompenaatlonlawaofC lfomla.Date PAID Z Z Applicant NEW RESIDENTIAL PLMB. :OFT. ate Recti I# p NOTICETO APFLICANT:If,after making this Certificate of Exemption,you should become subject to the Worker'Compensation provision of the Labor TOTAL: P N Code,you=at forthwith comply with such provision mor this permit shall be BUI -71LDING LU 9 deeed revoked. ` CONSTRUCTION LENDING AGENCY SEISMIC FEE CL IhercbyafOrenthat there ba concoction lendingagenry forthe pedorm ELECTRIC FEE O anceofthe work forwhichthb permit b issued(See 3097,Civ.C.) TOTAL: lender'.Name PLUMBING FEE LL F IMe^dera Address QTY. .MECHANICAL PERMIT FEE . MECHANICAL FEE OW I xrtifythut l have readthisapplicatlon.ed sntethattheab.,,Information C iscorred.Ixgres to compiywithall city and county ordinances and state laws PERMITISSUANCE FEES PAID: W relating to building construction,and hereby auth°rire representatives ofthis - F city to enter upon the above-mentioned property for inspection purpose. ALTERORADDTOMECH. ? (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Reckpt# V against liabilities,judgments,"Band expenses which may In any wayaccrue AIRHANDUNGUNITU'010,000CFM) SUBTO L: n Bald y In con enceof the IV ming of thisperrelt. AIR HANDLING UNIT(OVER 10,"CIM) CONSTRUCTION TAX s na of Applicant ontra )ate I EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX P D: HAZARDOUS MATERIALS DISCLOSURE - Wiiltheappllcan.or future buddingodavpantstare or handle havrdoua HEATING UNIT(TO 100,000 BTU) Date Recti t# material as defined by the Cupertino MuNetpal Code,Chapter 9.12,and the Ilealth and Safety Caders�Section 75537(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: ❑Yea II No Will the a ppilcaat orfumre building occupant use equipment or devices VENTILATION FAN(SINGLE RESIDE ISSUANCE DATE •vhlch tout hazardous air mntaMnnts as defined by the Bay Area Air - Quality Management District? i BOILER-COMP(3HP OR 100,003 BTUs aza &$ 2A B pl 4havereadtheh �ntsmalerlalsrequirementsunderChapter6.95of BOMER-COMP(OVER100,000BTU) the California Health&Safety Code,Section 25505,25533 and 7:534.1 NO 20 understand that if the building does not comently have a tenant,that it b my NEWREIDENIIALMECIL SQ.FT rnponmm ibility to notify the occupant of the requirements which must be el Es7x�L prior to issuance ofa Certificate of Occupancy. _ C��y , VUr�`T, tq Owner or authorized agent Date - TOTAL: ISSUED gal OFFICE COPY