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22369 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Prom Identification PERMIT NO. Bu Id ing Address: 22369 996 i%v ash nes ams: one: A A T ��,� CITY OF CUPERTIN&BU1LDING DIVISION t ;97— Lic.No: APPLICATION It PERMIT IJ BUILDING-ELECTRICAT PLUMBINGMECHAMCAL CATEGORY CONTROL X Architect/Engineer. Lic.No: r�3 QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO Address: trd 4(i PERMITISSUANCE ❑ 1:1 1:1LICENSED CONTRACTOR'S DECLARATION I hereby affirm that l am licensed under provisions of Chapter 9(comment APPLIANCFSRESIDENTIAL )OB DFSCRUPDON ingwith Sectton7000)of Divisim3ofthe Busiusand PmtevonsCode,andm (� y� license is In ful effect. PANELS Cis\- a� q_ 4 f- Q_ Licen Cl L1.1 .S�87215 LL7-1 fti Date Contractor ARCHITECTS DECLARATION 201-1000AMPS rc Z I understand my platy shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT. COC a d U Licensed Professional SIGNS ELECTRICAL p/�� 1III Tp''� �C� OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC //-�� 0�, "�. L., (hereby affirm that l am exempt from the Contractor's License Law for the ZO_3 following w... UWpMET[RORPOLEINSf. ` 6Ud P �' OZt.y� countywhich requlresa permittocorutruct,alter,improve,demolish,orrepair E F1 anystmmmpHortoiti antealwrcqubestheapperantforsuchper tto POWER DEVICES file a signed statement that he t licensed pursuant to the provisions of the ! / Z pOro� Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC DA eM 1il30 sion Sof the Business and Professions Code)orthat heleexempttherefromand �.' the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS-SWITCHIS-FIXTURES I ,s�/r� (``�'J O� apptcant for.permit subjects the applicant to a civil penalty of not more than L W� five hundred dollars OSS, NEW RESIDENTIAL ELECTR SQ.Fr. STORIES TYPE CONSTRUCTION Z ❑I,as owner of the property,or my employees with wages as their sole compensation,will do the work and the structure Is not Intended or offered for psale(Sec.7044,Business and Professmru Code:The Contractors License Law apse does net apply to an owner of property who Wilds or Improves themoo,and OCC GROIII' RIS.UNITSF- who does such work himself orthrough his own employees,provided that such improvement are not Intended orolfered for sale.If,however,the W ilding or TOTAL: Improvement b sold within one year ofcompletion,the owner-bullderwill have th ;dere of proving that he did not Wild or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD TONE APN I_I S as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE contractors to coretruct the project(Sec.7044,Business and Professlore Code: The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA) Wilds or Improves thereon,and who contracts for such pRojxes with a FEE SUMMARY .6p1I.cUs,O)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE Lj I am exempt under Sec. B k P C for this reason OUTSIDE FEES DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_ . Owner - Date RECEIPT T WORKMAN COMPENSATION DECLARATION FIXTURES. SCHOOL TAX Y_ N_ ❑l hereby affirm that I have a certigate of consent to self-Inure,ora RECE a ceaificate of Workers'Compereation huurarmora certified copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N 3800,Lab C.) RECEIPTX Policy GAS F.A.SYSTEM-OVER 6(EA) BUILDING DI VISION FEE IS r1 Com any Cerlltled copy is hereby furnished. GRGSE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE CD Certified ropy is filed with the city inspection division. CERTIFICATE OF EXEM PTION FROM WOR KERS' GREASE TRAY PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Recd t# (Thisseelon need not be completed if the permit t for one hundred dollars ($100)or ten.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_ 1 certifythat In the performance of the work for which this permit Is owed, I shall not employ arty person In any manner w as to become subject to the WATER SYSTEM/TREATING Workers Compensation laws of C.aI fo-t. Date PAID O Z Applicant NEW RESIDENTIAL PLMB, SQ.Fr Date Remi t# Z O NOTICE TO APPLICANT.Ifafter making this Certificate of Exemption,you should become subject to the Workers'Compensation provtiomo(the Labor TOTAL: _ W Code,you moat forthwith comply with such provisions orthts permit shall be BUILDING "E t j deemed revoked. SEISMIC FBG W — CONSTRUCTION LENDING AGENCY ISO IL I hembyaftirmthat there t a construction lendingagency forthe perform TOTAL: ELECTRIC FEE M Z asw.(the work for which this permit is Issued(Sec.3097,Civ.C.) PLUMBING FEE () O Lender'.No LL ~ lendces Address QTY. MECHANICAL PERMIT FEE MECHANICAL FGE L) Icertifythat l have read this application and statethatthe above Information O W Is correct.I agree to comply with a0 city and county ordinances and state laws PERMIT ISSUANCE FEES PAID: �. (1 relating tobuilding construction,and hereby authorize representativesofthb N ALTER OR ADD TO MECH. 1" Z city to ent upon the above-mentioned property for inspection purposes. Date Receipt# (W a to save,Inde fy d harmless the City of Cupertino AIR HANDLING UNIT([010,000 CFM) T ti P O against 11 ilitles,7a � e s,c an x nsss which may In anywayaccwe SUBTOTAL: agai Id City ro gaenr n ming of mi.Penni' AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX S tare of App ret/Cont- or Dat EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID: HAZARDO SM .4/1 LS UISCLOSUA Willtheapplicant orfuturebuild oceapant store or handle haeardous HEATING UNIT(TO 100,000 BTU) Date Recei t# m serial as defined by the Cupertino Municipal Code,Chapter 9.12,and the lkath and Safety Codr Section 2553Ha)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: \s ]V ❑Yes �No VENILATION FAN(SINGLE RESIDE ISSUANCE DATE Will the applicant orfuture building om+paN use the Ba Area devices which.Management airrict? ntas deRmd by the Bay Arca Au BOILER-COMP OFT'OR 100,000 BTR) JUL 4551� _ Quality Management District? ps Yrs FFo�No 4havemadtheth&a fet mater Sa tom255nt5533 and MM. of BOILER-COMP(DVIRTOO,OW BID) the costa rnia Heath k Ssfcty Code,SMlom 25505,255.3 and,Shat. I city YI °upidno understand that it the building docs no[arrcntly have atewnf that ttkmy NEW RESIDENTIAL MECH. SQ.FT AM Y MITI wipmuibBity to notify the occupant of the requimment which most be met �\ prior to Issuance of a Ccrtl ficam of Occupancy. Owner or authorised agent Date ISSUED 64\\`7"�• IC/"� �r 70TAL: OFFICE COPY