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22219 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification - Building Address: A -PERMIT NO. i Re � -� C ��� `�r�► ��. �P 22219 Q Q one: A 8?X7 ® CITYOPCUPERTINO-BUILDING DIVISION* p ' c° tad •.N"^=' a� {{QQ Lie.N. APPLICATION / PERMIT V s'���0 BUfLDINC-E.FCTRICALI'LUMBINGMLCHAMCAL CATEGORY CO Lp� Arc�hit5�/Ggineer. Lk. WI ELECTRIC PERMIT' FEE ' ., BUILDING.PERMITINFO, Address: Spr#AE PFRMITISSUANCE - n LICBNSEDCONTRACFOR'5DECLARATION ' �T" I hereby affirm that l am Leaned under pm%,Wonsof Chapter 9(cormnenc- APPLIANCES-RESIDENTIAL JOB DESCRII'RON inenexi tolell7000)ofdeffeon3 oftAe Businesaand ProleselonsCode,and my las. Rcenee la dJOA orc)of Mvied. PANES 1 V Lima.Clam LIc.N L�� Date Contrador - 0 ARCHITECT'S DECLARATION 201'1000 AMPS ,gyp+rc0 7p7pC [understand my plata shall be used an public records. OVER 1000 AMPS $Q.FT.ft���.0yyy0R AREA S/SQ.F!'. E U Licensed Professional + SIGNS ELECTRICAL I�00 E.®, OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC ' - Il( I \ 7L., a Thereby affirm that am exempt fmm the Contractor's License law for the - ^' county greasog requires rmitto1 oxmuft and Professions Code: d or (� n�� K -� O F� which y city TEMP.METER OR POLE[NST. M C� any strecrum requireor tos Issualto alsoreuiesthlmprovnt forsch,orto repair - �G a any atsvcture statement tementa that he is ibensedi pursuant t to the provision, ofpermit e POWER p�C. K V Ole a signed Mcens eLa that he to licensed pursuant it the pro 7000) of the 3w Contactor'eLiceneawChapter9(ronmencingwithSectlon700)ofDiet. SWIMMING POOL ELECTRICaT O eion 3 ofthe Businemant Pro(e®IowCade)orthat he is exempt themfromand UATUD the basis for the alleged exemption. Any violation of Section 7MI.5 by any p5 a^ applicant foraermit subjectsthea Bent to civil i ofn.t morethan OUTLETSSWITCHFSEXTURFS L� '�21 (� t1�(,�' E civ hundreddollarsthe500). NEW RESIDpdrI7AL ELECTg STORIES, TYPECONSIkL'CTION �j.• ❑I,as owner of the property,or my employees with wages as]heir sole SQ FT C ¢ compensatlon,wllt Bothe work andthenmdvrebnot intended or offered for O sale(Sec 7014,B.Arssand Professions Code:The Contactors License Law does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP RIS.I1NTTS EEE whodoessuchwork himself or through hiaownemployees,provided that such improvements am not Intended oroffered formic.If,however,the building or TOTAL: Improvementissoldwithinoneyearofcompidl.gtheowner-buliderwlllbave �_ enol pmving that he did not Wild or Improve for purpose of sale.). QTY, .. PLUMBINCPERMIT' FEE FI.ODD IDNE APN I as owner of the Property,am exclusively contracting with licensed pFRMIT ISSUANCE W ntrade to censtrud the prokd(Sec.7014,Buslnem and Professions Code: C.ntadOrVTTmme Law does not apply to an owner of property who " Wilds or Improves thereon,and who contracts for such ptpjects with a AL: VENT-WATER(EA) �' [y5I[actor(.)licensed puesuant to the Contractor.License Law. 'FEF.'SUMMA RY._ , LJ I am exempt under Sec. B 8e P C for this,reason BACK FLOW PROTECT.DCVICE - Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N RFCEDT p -WORKMAN COMPENSATION DECLARATION❑ FIX'IURF_S TRAP PER T / Co SCHOOLTAX Y N :1 hereby af(Irm that 1 have a certlBnte of consent to self-Inaura,ora l©s RECEIPT N cedlfma df Workem'Compensatfon Insurance or a certified copy thereof(Sec. GAS EA.SYSTEM-1 BVC.I OUTLETS 3800,Iab C.) - ♦(� PARK FEE Y N_ PolicyN RIiCEIPE N Com any - GAS EA.SYSTEM-OVER4(PA) BUILDING DIVISION 1'IiES 0Cerlfied copy lahereby furnished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE ❑Certified copy is flied with the city Inspection division. CERTIFICATE OF PXEMPEION FROM WORKERS' GREASE TRAP 'PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recei tl �� ' (Thlsxpermitctionneed not completed if the pert is fee one hundred dollars (1100)orles,.) 1 I. WATER HEATER w/VENT/ELECTR ENERGYFEE Y N I certify that In the performance Of the work(orwhich this permit is Issued, ' 1 shall not employ any person In any manner so as to become subject to the 4VATCR SYS7IId/TREATiN'G Workea'Compensation Laws of California. Date PAID O Z Applicant Z D - NOTICE TO APPLICANT. f,afier making this Certi!irate./Exempllon,you 'N`EWRESIDENTIAI.PLMB. SQbT. . Date Recel t# should Wcorre sub}•ct to the Workers'Comperuatbn provixtov o(lhe Labs TOTAL: N CWgyoumustf.thwithmmply Mthsuchprovislons.rthi permltshallbe _BUT TNG e 9 deemed revoked. '- aCONSTRUCTION LENDING AGENCY SEISMIC FEE s Thereby work for tisaconswdssu ld(Sm aW,Civ.C.) pedorm- IOTA ELECTRIC FEE Cu � Z ante of the work!or which this perMlblmued(See 3097,CIv.CJ' V'O Lenders Name - 1, PLUMBING FEE QTY. 'I MECHANICAL PERMIT '.t?'EE 1 ly F Lend.r'sAddress MECHANICAL FEE xC O O W Icertlfythatl have read thisappBra(IonaM nate that lheabove in(ormaHon ( - C isoomet.l agree to complywith all cityand county ordinances and nate laws \ PFRMRISSUARCE V FEES PAID: N -relating to building construction,and hereby authorize representatives of this r Z city to enter upon the abovcmentloned property for inspection purpose: ALTEt OR ADDIO MECIT - ♦ {�/ _ (We)agree to mve,Indemnify a^d keep harmless the City of Cupertino - Date Receipt# against llablllHes,judgments,coneand expenses which may in anyw attme AIR HA (We) NC UNIT[7010,000 CFM) SUBTOTAL; aga Wtsald Cdylnconsequr1 o&&a granting of this permit. q AIR HA NDLING UNIT(OVER 10,000 CPM) CONSTRUCTION TAX ' Ignamre o! pp lent/Contrador - D e 6 F7(HAUSTHOOD(W/DUCl7 CONSTRUCTION TAX PAID: HA7ARDOUS MATERIA SCLOSURE Will the appilranl or future hugding oavpantstorc.r Wn hazardous IIFATING UMT(T0100,f1D0 BTU) Date RCCeipt# materislm defined by the Cupertino Municipal Code,Chapter 9.12,and the - — Ilcalth and Safety Code Section25532(a)7 ' HEATING UNIT(OVER 100,000 BTU[ 'TOTAL ❑Yes e❑No Will the applicant or(uture building Occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE which coot hazardous atrrict? ants as defined Wythe Bay Area Air . Quality Mavgemem D'utdct7 BOILER-COMP(3FE'DR 1W,Mq RTU) ?h '� Yes ❑Na eAf® Ihaveread Health a afet materials requirement, onsre5nlsunder Chapter.1 of BOILER-COMP(OVER ifA,(100 BTU)" the understand t Health b Safety Code, of currently 2550.5,have at and 255X.I . understand that If the building does not currently have atenanq that it is my NEW AFSIDFNTIAI.MECFi. SQ.FT. O 1991• resp°nsibllllyton°ofythc Lcte ofnto pancquircmentswhkh must be mrl AUGf'IVl7 b (+ pdorto issuance.fa Ccrtlficat.of Ocmpanry. Ownerm.uthoHzed—gent. . Date Jif ISSUED It Y: TOTAL: t`a" OFFICE COPY