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22431 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY Building Pm'ert lJentl(ication PERMIT NO. Bu Rding Addres,: - 22431 To L„ l/.,te.le CITY OF CUPERTIN66UILDRJG DIVISION APPLicATZ79UMMAI71= Co }/ r LIa.Ncx APPLICATION /PERMIT N��I KL/ SON / AL BUILDINC—MFCTRICALPLUMBING-MECHANICAL CATEGORY CONTROLx Itect/Engineer. Lk.No: QTY ELECTRIC PERMIT; FEE BUILDING PERMIT INFO naa _Q jgpX p/Ile /p�..t�11 PERMITISSUANCE - ❑ El _ . LICENSED CONTRACTOR'S DECLARATION I hereby a(flrmthat l amlicensed under provkdonsal Chapter9(commose - APPLIANCES-RESIDENTIAL JOB DISCRI'HON Ingwlth5ection7000)af DiAs.3ofthe Busln.and PmfesdomCode,and my licen,e is In(u fo deffeR. /O QO PANES License Cb Llc p' O OO Date Cone actor UP TO 2DOAN6 ARCHITECTSpublirerorAT10N 201-1000 AMPS OVER 11000 AMPS - SQ.FT.FLOORAREA S/SQ.FT. AZre mv O [understand my plane shall be udubllcd.. 2 Licensed Professional - SIGNS ELECTRICAL ` «Q Q OWNER-BUILDER DECLARATION - SPECIALCIRCIIT/MISC I,,, ]hereby.a.(ectln731.5,ame pt menBiro ossa Contractor's License Law fort he _ - Z po� fogawing reason.(Section 711115,Buelners and Profemlone Code:Any ctty or 0M!g county which requftes a permit to construct,alter,improv,demolish,or repair TEMP.METER OR POLE[NSF.' , `� a anystructure prior to its Issuance,also requImsthe applicant for such permit to ppkygg DEVICES yd c. flle a signed statement that he b licensed pursuant to the provisions of the ' tor's Llcerue Law(Cha 9(commsnclnwith Se1 <on 7000)cf DIW- �+0�' Contracslon3o(the Buslneeaand Pro(eserbns Cade)orehaghelaexempttherefromand S'WQdMING POOL ELECTRIC VALUATION yd g the basis for the alleged exemption. Any violation of Section 7011.5 by any OUTLETS-SWITCHES-FIXTURES - C`2 applicant Jura permit.ubjectstheapplicant too civil penaltyofnct morcthan C`p five hundred dollars(5500). NEW RESIDENTIAL ELECTR SQ.FT. j.. F-1 1,as owner of the property,or my employees with wages as their sole STORIES TYPE CONSTRUCTION compensallon,willdothe work andthestmctum is not intended or offend for Dsale 1S,,7046,Businessand Professions Code:The Contrsewes License law Q does not apply to an owmr of property who Wild.or improvns the.,and OCC.GROUP RES.KNITS who does such work himself or through his own employees,provided that such Improvements arc not Intended orofferedforsale.If,however,thebuilding or TOTAL: Improvement lasold withlnomyearofcompletio,theowner-budderwlll have tkq-�urden of proving that he aW not Wild or Improve for purpose of sale.). QTY. PLUMBING PERMIT, FEE FLOOD ZONE APN "L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE contractors to construct the project(Sec.7046,Business and Professions Code: ZaQp ' The Contractor's License law don not apply to an owner of property who ALTER-DRAIN VENT-WATER(EA) Wild,or Improves thereon, and who contracts for such pwjem with a c actor(.)licensed pursuant to me Contractor's Lianas Law. FEE SUMMARY LJ I am exempt under Sec. B k P C for this reason BACK FLOW PROTECT.DEVICE DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N-PI S' Owner Date RECEIPTp T WORKMAN COMPENSATION DECLARATION FIX.fURES PFR TRAP SCHOOL TAX Y_ N_ ❑I hereby affirm that I have a medicate of consent to selLsurc ln ,ora RECEIPT# evrtlBcateof Worken'Compose.tlonlmurmce ora certified copythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N 38W lab C). GAS EA.SYSTEM-OVER 4(EA) BUILDINEJF Vr ION FEES Coma ly /. Certl e copyla hereby vn shed., GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE ❑Certified copy Is filed with the city Inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRA' PAID COMPENSATION INSURANCE S# - (fhlssectlon need not be comp)TI Rtheperms lamforahundred dollars SEWER-SANITARY-STORM EA.2(OFL QO Date Receipt# 0100)or less.) ENERGY FEE Y— N_ I artily that In the performance ofthe work forwhlch this permit is lasued, WATER FiFATFdt.W/VFM/©'�� 1 shall not employ any person in any iianner so m to become subject to the WATER SYSTEM/TREATING Workory Compensatlonlawsof Callfornla.Date _ PAID OZ Applicant NEW RESIDENTIAL PLMB. SQ.Fr. ' - Date Recei tq Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subje t to the Workers'Compereatlon provblotu o(the Labor TOTAL: � N Cod,ym=stiomhMthmmply Mthsuchpms iomorth6Ne tshallW BUILDING FEE deemed revoked. W' CONSTRUCTION LENDING AGENCY - SEISMIC FEE ' I1 I hembyalirmthat there is a construction lendingagenry forthe perform TOTAL: ELECTRIC FEE Z onceofthework forwhlchthlapermit istented(Sec.3097,CIv.C.) Ino OO !ander'.Name PLUMBING FEE .Ofl F- Lenders address QTY. MECHANICAL PERMIT FEE MECFIANICALFEE LL O I certifythat i haveread thlaappliation and stntethattheabove information O W iscormctlagectocomplywithallcityandcountyodnanmand stela s PERMIT ISSUANCE FEES PAID: r1 relating to building constmetion,and hereby authorize representatives ofthis F N city to enter upon the above-mentioned property for inspection purposes. ALTIMORADDTOMECH. ? -(We)agmxtosave,indemNdi (yand keep harmless the City of Cupeno Date Receipt# V agaI th billties,' dgmenb,costs and expenam which may inanywaysecrue AIRHANDIINGUNH(rOI0D)0CFM) SUBTOTAL: • ag uld Cit ncon uence oftM gra rating of this permit , // R/ ATR HANDLING UNIT rovFR 10,000C r•M) CONSTRUCTION TAX ,Atgefatureof Applicant/Contractor Date/ EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE -. Will theapplicantorfuture building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t# material as defined by the Cupertino MuNcipal Cade,Chapter 9.12,and the Health and Safety Code Sedion25532(a)? HEATING UNIT(OVER 100,000 BTU) I•; O ❑ Yes MN. Will the applicant or(utum building occupant use equipment or devices VENTILATION FAN(SINGLE REST@ S UANCE DATE which emit haeardous air contamlnsntsas defined bythe Bay Area Air JI1L 181001 1991 _ Quality Management District? BOILER-COMP OFT'OR 100,0(0 BTU) 11410----- ❑No 4hYrsaeereadthe hazallousmaterials mquirementsunderChapter6.95of BOMER-COMP(OVER 100,0)(01BTU) the ersta dta I hat if the building Cod,Sections25505,25533have t and 2S534.] W r understand thaUfthebullding does not currently have atenanL that ltlsmy NEW RESIDENTIAL MECH. :iQ.Ff. responsibility to notify the ons pant of the requirement.which most W met prior to Issuance of a Certificate of Occupancy.' - - Owner or authodzed agent Date TOTAL: ISSUED 0 �� OFFICE COPY