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23104 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY Building Pro eC identlliration ' - - PERMITNO, BuIlding Addreaa:�D a , - 23104 ams: one: m 732- 70'4 CITY OF CUPERTINOIBUILDING DIVISION C. I or Na _ e.No: APPLICATION / PERMIT 6 i� G BUILDINGELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL A Ambietl/Engineer. Lie o: ,QTy ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address PERMITISSUANCE ❑ ❑ LICENSED CONTRACTOR'S DECLARATION I hereby affirm that l am licensed under prwasor.of Chapter 9(commenc APPLIANCESRESIDENIIAL JOB DESCRBTfON Ing with Section 700(fid Division 3oflhe Buelneesand Pmfesal...Code,and my Rcense I.In fu6(a orc�ayC effect. _ PANELS W" Lken Clam Lie.A - Dated of Cantraaar - -� I AR 201-IODOAMPS . NZZ Iundentandmyplasuehallbeumdaapub records. OVERIODOAMPS nSQ.FT.FLOOR AREA S/SQ.FT. 00 Licensed Professional SIGNS ELECTRICAL ` ,• L assn' D OWNER-BUILDER DECLARATION ss as ,L.,�6 Ihereby axon. that 7exemptfromthe Contractor's Code;Any for/he SPECIALCRCUIT/MLSC II,\V/I following and Pm(eabna Code:Anycityor O f: TFMP.MEIIiRORPOLEINST. / 3 1 ��� countywhkh rcqulresaPermit/ocomtvct,alter,impmve,demolbh,ormpalr g any etmctvre pdorlo lb Lsauance,eiw rcqulrestheappBcent(arsuch perMtto POWER DEVICES DA E K1 +I s file a signed statement that he b licensed pursuant to the provision of the Contractor's License Law(Chapter 9(commencing with Section 7000)of DIW- F Orn elon3o(ihe Business and Pmdesslosa Code)arthal Fels exempttM1erefromand SWIMMING POOL ELECTRIC VALUATI( yd ig the basis for the alleged exemption. Any violation of Section 70115 by any - � p applicant fora permit subjects theapplinnt too tlWl penaltyof nal morethar 0[TILEISSWITCFif5HX'NRES v 8 flue hundreddollar. pro SQ,FI• STORIES TYPE CONSTRUCTION I� RESIDENTIAL ELECTR �n ❑Las owner o/thheeproperty,or my employees with wages act thele sole NEW RESID Q, compensation,70K Busio the ness and rkand thesh Code;The Contractorot Intended proffered for q doe not apply aptly to an alnow owner of properProff6doety who builds C Improves License thereon, ereon - (',aj;� donnotsucit torkhandrolpmpertywhar,emayers,povidedrroRand ch OCC.CROUP RES.UNITS K whodomeau,am kMmve dedoraughed ow ile.1, oumveavhe lull ing or improvement untold ithindneyearofcompreale.tth nv-builderwilIngw TOTAL: Improvemeof nt bwidg than he did buil por improve for rurposerwiilhave tlLj1,as nwner of the phpertynot am exclorlmpmvefacting with kale.). QTY. PLUMBING'.PERMIT FEE FLOOD TONE APN Lcart I,cue owner tr the property,am exclusively Business ens and contracting with licensed ppgMlT ISSUANCE The Conon to mr Licen the project(Sec.7014 to ness entl of property Code: The Caorfropr's es Cher Law don nal apply et an owner of property who ALTER-DRAIN As VENT-WATER(EA) Wilda or Improves thereon,and.who mntncts ice suchsee phojem with a cq)}�+�torexemtunder ant Bar, the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY L,J I am exempt under Sec B k P C for this reawn DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N - 1 Owner Date RECEIPT M— WORKMANIhavea SATION DECLARATION FDnURFS PER TRAP SCI IDOL TAX Y N QI hereby affirm that)have o martificate of consent to opytnmre,or a RFLEPT a ce00,lAeof Workers CompevallonTvurann¢a¢rtl(kd copy thereof(Sec. GAS FA.SYSTEM-1 INCA OUTLETS. PARK FEE Y N " 380Q 4b C.) policy ` RECEDING Of Cam an � GAS EA.SYSTEM-0VERIIRA)Y BUILDING DI VISION FOES Certified copy It herebyth(he city GREASEANDUSPRL WASTE INTERCEPTOR PLANCHECK FEE nCertiBed copy V filed with the inspection division. ' CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID COMPENSATION INSURANCE r SEWER-SANITARY-STORM EA.X07r1'. Date Recd t# (Thls¢ctlon need rat be complcted I(the permit V(Drone hundred dollare ($100)orless.) WATER HEATIR W/VENT/ELCCTR ENERGY FEE Y N Irertifythat a rfoman¢oftheworkforwhichtMep.mitlel.sued, (shall notscop ay person In an nnerm uto o te`eubYC'W wATERsYSDT1/TRCATH,,G PAID Work, Co aHon I..al amiss Date y O Z Appil¢ NEW RESIDENTIALI'LMB. SQ.FT. Date RC0.'1 t# Z 0 NOTIC A :IL aft. -Un-,1h Ce finteof Eac Ion,you should became.ubjc ache workers'Comps an pmvIdt aithe Labor TOTAL: fr W Cade.you maatfart Ithmmplywithmetsp Ioneorthbp=.1alibe - BUILDING ' > deemed revoked. a0 t CONSTRUCTION LENDING AGENCY - - SEISMIC FEE I hereby affirm that there ct a construction iendlngagenry for the perform- ELECTRIC FEE Z arm of the work for which this cr It is iuued ee 3097,CIv.CJ - TOTAL: ' V O Tender's Name PLUMBING FEE LL F- Lender'.Address QTY. MECHANICAL PERMIT FEE MECHANICAL PEE •' OW Imrt Itythat lM1 ad thlsappll¢llonand state thatl ea o ormatlon C iscorrcct.Iag tammplywithall tltyandmuntyomdlnan¢son .bis laws PERMITISSUANCE FEES PAID: >- W roatingtobu Ing construction,and hereby authorize representatives of this - - „ Z my to enter nthe abovo-mentlo property for Inspection purposes. ALTER OR ADDTO MECH. (We)a eta.ave,Indemni and keep harmless the City a(Cupertino Date Receipt# V againstll Iltks,jadgments, de.pen.eewhkh mayln anywa acvue AIRHANDLING UNIT(TO 10,000CFM) SUBTOTAL: ago s in corseq t grenang of this perrnit. AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX g rex App ¢n ate EXHAUST Hoop(w/Doers- CONSTRUCTION TAX PAID: HA ADOUS MATIiR1A ]SOL URE WI1ltheapplica aria building tstomor rdk hanardovs HFATINGUMTITOIN,000BTI7) Date Recei I# cratertalasdefire y the Cupertino Municipal Code,Chapter 9.1$and the - FkalthandSaf ode Sectlon2SS3](a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL• n Yee M No Will the Applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) �I$SU/�i.16E DATE which emit hazardom air cortaminanlaas defined by the Bay Area Air 6i 1 6/ Quality Maragement District? BOILER-COMP©HPOR 100,000 BTU) - 4,Y.•e [�I No 16 'I(�Q avere.dthehazarTsms. teriaismquimm ntsunderChapter6.95of BOILER.COMP(OVER 100,000 BTI! DEC 1saV� the Calif¢ i.Health k Safmy Code,Setllona 25505,25533 and 25534. I understand that if the building does not currently have a tenant that it is my NEWRFSIDENHALMECH. SQ.FT. responsibilityce of a Certificate of dike requlremenb which mull be met IItYu - prior to Lssuantt o(a Crrtlficate of Occvpanry. �'II.Y �.��..0/yaurtaH/, Owner or authorlud agent, Date TOTAL: ISSUEDBY:—'.sant-1i ac/ OFFICE COPY