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22929 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY Building Preen Identification PERMITNO. Building Address: `"-`7 q L] ,� 2 . 22929 wners one: q CITY OF CUPERTINO-BUILDING DIVISION Cont rani^: LIr.No: APPLICATION / PERMIT BUILDING•FLUCTRICAI PLUMBINC-MECHANICAL Let r2�14 CATEGORY CONTROLp Architect/ neen .k. o: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: PERMIT ISSUANCE ❑ ❑ •❑ LICFNSEDCOense, OR'S DECW ION I hereby at(Irm that tem lkense I under Prov of ChelXer9(rommeno APPLIANCES-RESIDENTIAL JOB DPSCRB'I10N Ingwith )ofon3 o(lhc Bue and Pm(eealoneCodeand my time.le Infull form andaffect. PANELS License Lk.. 1B P Date Contractor ARCHITECTS DECLARATION 2014000AMPS 1Q±�reO Zp I understand my Ohm shall be used as public remrd> OVER 1000 AMPS Licensed Professional ES©,FLOOR AREA s/SQ,FT, E� nal SiGNSELECTRICAL NQQQQ 6 tLC�, OWNER-BUILDER DECLARATION e Ian aI hereby SPECIAL CIRCUIT/MISC YVY 2t, following reason. 7exempt(ro esthe sad Prefissio License law fore he O q�y following reason.(Section 7031.5,Business and Professions Code:Any city �, t"❑ empty which requires apermit toconstruct,alter,Improve, m ve,deolbh,or repair TEMP.METER-OR POLE INST 4 ❑Qany structure prior to Its Issuance,also requires the appBcent for such permit to POWER DEVICES DA V file a signed statement that he is licensed pursuant to the powlslom of the L= LLau �0: Contractor's Licerue Gw(Chap[er9(mmmentlngwllh Section7000)o(Divi- SWIMMING POOL ELECTRIC , X05 sion3oftAe Business and PmfemiomCode)anther heb exempttherefrorand VALUATION the basis for the alleged exemption. Any atlolatk n of Section 70115 by any �t O� appgant Mora permit subjectstheapplimettoa civil penalty ofnet morethen OUTLETSSWITCHESFIXTURES S-0 five Lasownerofthepr. NEW RESIDENTIAL ELECTR STORIES •, `J TYPECONSTRUCTION I,as owner undred ars($ roe �•hT �n property,work,a or my employees with wages r offered for their sok nd the strucrom is ent Intended M saldo (Sec.70Kpply Business andfpmpelom Code:The Contractorimprorshereon Law 3 doesnot applymrkan ownerofproperty who nIndsoriepp.iiedthat and OCC.GROUP RIS.UNITS C• whodoementsa not Inttededomughhisowals.If owe,ertheedthatsuch Improvementsarena Intended earofred(orsale.thea nveg deer ilI have TOTAL: Improvement braid within one yearofcompinlory the owner-bullderwlll have thg burden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD LONE APN u L as owner of the property,am exclusively contracting with licensed pERRMRIffiIIANCE ronHxctors to mvwtruct the project(Sec.7044,Business and Profewv loCade: The Contractor's License law does net apply to an owner of property who ALTER-DRAIN&VENT (EA) Wilds or Improves thereon,and who coneratta for such projects with a �q➢S[+ ec darts) pursuant to the ContnRor'a License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY U 1 am exempt under SB&P C for this resson DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N- - OUTSIDE FEES Owner Dare RECEIPT.a WORIONAN COMPENSATION DECLARATION FIX717REce PER THAI' SC1100L TAX Y_ N— ❑1 hereby affirm that 1 have a certllkate of consent to eel(-Imre,or RECEIPT N certificate of Workro'CompemaHonlmurance ora certified ropy tAerco((Sec. GAS EA.SYSTEM-1 INCA 3800,Lab C.) PARR FEE Y— N_ Polity M CAS EA.SYSTEM-0VER 4(EA) RECEIPT It C a^Y BUILDING DIVISION FEES ertified ropy is heed with to city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE Certified copy Is tiled with the city inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWERSANITARYSTORM EA 200FT Date Remi tN (0).,I.lon need not W completed If the permit b foram hundred dollars ($11crify that WATER HEATER W/VENT/ELECTR ENERGYFEE Y N lcenot that In the person in anfthe marear sa as t Iscro e,rmitsubject c Issued, — I shall not employ any person In any manner n m to become subject to the WATER SYSTEM/TRFATING Worken'Comprnsatlon laws of California.Date PAID OZ NOTIAppliCE rat NEW RESIDENTIAL PLMB. SQRT, Date Remi til Z Z NOTICE TO APPLICANT.If,after king this Certificate of Exemption,You Fshould become subject to the Workeri Compemetion provisions of the Labor TOTAL: tl3 Code,you at forthwith comply witheuch provbioworthis permit shallbe > deemed revoked. BUIL12ING ' CLCONSTRUCTION LENDING AGENCY SEISMIC FEE I herebya(firen that there Is a commuction lending agency for the pertormry ELECTRIC FEE Z arm ofthe work for which this permit is Issued(Sec.3097,CW.C.) TOTAL: 00 Lender's Name PLUMBING FEE LL I— lanarr.Aaarew Q7•Y, MECHANICALPERMIT FEE MECHANICAL FEE O W Icertifythat I bevereadthb application and statethatthe above Information bcerren.I agree to comply wither city and muntyordlnanresandstatelaws PERMIT ISSUANCE FEES PAID: IL relating to building construction,and hereby authorize representatives;o(thb I- Z mT'O city to enter upon the above- entloaed property for inspection purposes. ALTERORADDMECH. (We)agree to save,I^demNfy an d keep harmless the City of Cupertino Date Receipt# V against liabWties,judgments,meta and expenses which may l^any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: against said City In mnsequ ence of the grant Ing his permit. Q ` AIR FIANDLING UNIT(OVER 10,000 CPM) CONSTRUCTION TAX gnatore of AIlcant/Contrector 1J ate , EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS C Will the applicant or future building emopa at. oLOSUREre or handle hazardous HEATING UNTT(TO100,0001HU) mDate Recei f# aterial as defined by the Cupertino Municipal Code,Chapter 9AZ and the I leallh and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: RYen M No ill the applicant orfutum building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE which rout hazardous air contaminants as defined by the Bay Arca Air Quality Management D❑istHct7 BOILER-CAMP DHP OR 100,000 BTU) PAID 4 Yes N No have read the baza us materials requirem ants under Chapter 6.95 of BOILER-COMP(OVER 100,000 RTU) the GlEfemla Health&Safety Code,Sections 25505,M533 and 25534.1 OCT 31 1991 understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH, SQ.F .. ^ responsibility to notify the occupant of the requirements which mart be,met prior to Issuance of a Certificate of Occupancy. CITY OF CC`.U+a`P-E'H�I`INU�'�p4 Owner or authorized agent Uale ISSUEDBY: TOTAL: OFFICE COPY