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22621 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Pro'ca Identification 7 PERMIT NO. B.Uding Address: 22621_ o ss wners anter More: p e—� �� c�)r t 1 e�k�'l) CITY OF CUPERTINO-BUILDING DIVISION © ^� 1 contractor's ante, ue.N.: APPLICATION /PERMIT CJ — \ BUILDINGELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL N Architect/Englnmr. Llc.No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address PERMIT ISSUANCE LDCONTRACTOR'S DECON , D;]'' (1,❑ I hereby afnrmthatI amecensedu ofChapter 9APPLIANCES-RESIDENTIAL JOB DESCRIPTION in Seaton 7")of on3 ofthe Busloessand Prro(esionsCocteand my license is In boll force and effect. PANELS eClan c.0 Date _Contractor a� ARCHITECTS DECLARATION IDI-1000A.MP8 �2 I understand my plana shall be used as public records. OVER1000AMPS SQ.FT.FLOOR AREA 5/SQ.FT. CO z(7 Licensed Professional SIGNSELECTRICAL �< OWNER-BUILDER DECLARATION SPECLYLCIRCUIT/MLSC t, Ihereby affirm that l am exempt from the Contractors License Law for the OZ Z F- fol1owing reason.fSealon 7031 S,Business and Profesbns Code:Any city or TEMP METER OR TOLE INS7. lr� countywhichmquiresapemttommtrua,alter,impmvgdemolbh,ormpair 1 anyatrodurcprb tolt.Wuancqalsorequi.theappBcanlforsuchperMtto POWER DEVICES C n file a signed statement that he Is licensed pursuant to the previslons of the Oes�3Contraccats License Law(Chapter 9(mmmencing with Section 7000)of DIN- SWIM)AING]OOL ELECTRIC 0 slon3 ofthe Business and Profesloru Cods)orthat het exam therefromand VALUATION y3 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFIXT CRFS applicant for a permit subject the applicant to a civil penalty of not mare than five hundred dollars($50M. NEWRIDENTIALELECTR SQFI, STORIES TYPECONSTRUCTION 7 I,as owner of the property,or my employees with wages as their sole compensatien,w91 clothe work and thestructure Is not Intended or offered for ,J O sale(Sec 7614,Business and Professions Code:The Contractors License law qt'$ does not apply to an owner of property who Wilds or improves theremnand n,5.. who does such work hlmselforthmugh his own employees,provided that such OCC.GROUP RES.UNITS Improvements am not Intended oroffered formals.If,however,thebullding or TOTAL: Improvement bsoldwlthln oneyearofcompletiogtheowner-budderwill have 1n�vrdeo of proving that he did not build or Improve for purpose ofsak.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN u,deo owner of the property,am exclusively=trading with licensed ppRM171SSUANCE contractors to mmwct the project(Sec.7044,Business and Professlom Code: Has Contrector's License Law does sat apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) bu lids ar Improves therms,and who contracts for such Iuppets with a cn64acior(sI licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY U I am exempt under See B&P C for this reason " Omer Date DRAINSFLCOF,ROOF,AREA,GOND. SANITARY RECFII'I'N WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y_ N_ ❑I hereby affirm that I have a certi6ate of consent to self-Insure,ora RECEH7 N cartifiamofWorkers Compensation insurance ora certified copythercof(Sec. GAS EA.SYSTEM-1INCA OUTLETS PARK FEE Y N 3800,Lab C.) RECEPTN Policy N GAS FA.SYSTEM-OVER d(EA) BUILDING DIVISION FEES Cnm ray [Certified ropy Is filed w tum e city PLANCHECK FEE []Certified mpybfilsd with the city Inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.260FT. DatCecel t# (This section need not be completed lithe permit Is for one hundred dollars ($100)or I. WATER HEATER W/VENC/h1.ECTR ENERGY FEE Y I certify that In the perfomvnce of thework forwhich this permit I.Issued, I shall not employ any person in any manner ro as to become subject to the WATER SYSTEM/TREATING Workers Compeneatlon Lawa of Callfomu.Date PAID OZ Appllant NEW RESDENITALPLMB. SQF7. Date ecei t# Z O NOTICETOAPPLICANT:IL after making th6Certlfcateof Exemption,you should became,subject to the Workers'Compsmatlon provisions of the Labor OTAL: CN Code,you must forthwith comply with such provisions orthis permit shall be BUILDING W j deemed revoked.CONSTRUCTION LENDING AGENCY SEISMIC FE ll Ihereby affirm that there is a mnstroction lending agency for the perfore, ELECTRIC ' 7 ZanceoftheworkforwhlchthLpermitblvsuedl5c.3097,CIv.C.) TOTAL: U O lander.Name PLUMBI EE LL Lenders Acarus QTY. MECHANICAL PERMIT FEE MECH 1 L PEE UIcaAlfythatlhavercadthbapplia0on.ndstatethattheabovelnformalon O W lecoreact.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES C relating to building construction,and hereby authorize representatives ofthla r W city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. ? (We)agree to Indemnify an d keep harmless the City of Cu Forma Date Receipt# V agaWtliabillties,judgmen ,cart sand expenses which mayin anywayaccrue AIR HANDLING UNIT 170 10,000 CFM) UBTOTAL: against Chymous 6y ¢ fthagrartingofthi.purnut. CONSTRUC77 NTAX �•/ n / G/ AIR HANDLING UNIT(OVER 10,000CFM) tore of Applicant/Contractor J Date! EXHAUST HOOD(W/DUC) CONSTRUCTI NTAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous HEATING UNIT CFO 100,000 BTU) Date Recel t# material as defined by the Cupertino Municipal Code,Chapter 9.11,and the Health and Safety Code�+—SS�eaton 2S532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: F]Y. No Will the epplia fit or future build ing occupant use equipment or d evices VFNTILATION FAN(SINGLE RFSID) ISSU NCE DATE which emit haaardous air contaminants as defined by the Bay Area Air Quality Management District? BOILER-COMP OTU'OR 100,000 BTU) Ye No have read the haeardous materials requirements under Chapter 6.95 of BOILER.COMP(OVER 100,000 BTO) the California Health&Safety Code,Sections 25505,5533 and 25534.I understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.pT respomibilitydo notify the occupant of the requirements which must be met prior to Issuance of a Certificate of Occupancy. �w Owner or authorised agent Data ISSUED BX7. TOTAL: OFFICE COPY