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22416 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project IdentificationPflTN'O. Building Addran: ; e �+r 22416 Owneb (ojt©_d � a� W,ew arngewk OwlP1APY�iGa �`' CITY OF CUPERTINO-BUILDINGDIVISION hJ A Con ' lc 4�,��>t< an« APPLICATION /PERMIT `�7-I f ` �\ BUILDING-ELECTRICA4PLUMBING-MECEMNICAL CATEGORY NTROL N �. Architect gmeaA Lk.No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: PERMITISSUANCE ® ❑ 1:111LICENSED CONTRACTORS DECLARATION IhthSy affirm homsed uMprovisions and miehapter9 e,and c APPOANCIS-RESIDEN77AL T�JOB DFSCIjQPITON Incense I.ectlon f.rmafDlvatlon3oflheBusinessand Pro(eaalonaCode,and my PANELS license to In foil forcr and effect. 1 I rT V r1'r\ J kte bat C D DateC.n Or UP TO 2DOAHM NI IODDAMPS ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT. 0wre b ]understand my plans shalbe used as public records iti L Licensed Prefessloml SIGNS ELECTRICALVT D GG< OtIamexNLDERDEC4IRATION TER ` IN y ET SPECIALC]RCUIT/MLSC at 5 1160, X'. jg Ihercbya(firmthatlamexemp from Contractor's Llrenm Law(orthe O F- following reason.(Section 90315,Business and Professions Code:Any city or TEMP.METER OR POLE INST. K<EL county which requlresa permit to roretruct,alter,Improve,demollsh,orrepalr ^^•• N .a anystrueture prior to Its tssuance,also requiresthe applicant forsuch permit to POWER DEVICES CATS Q ��/c)/! file a signed statement that he at Ilmnsed pursuant to the provisions of the O n'I�n Contractor's License Law(Chapter 9(commencing with Section 7000)of DWI- SWIMMING POOL ELECTRIC ALUATION Eh05 sion3 ofthe Business and ProfusionsCode)orthat he is exempt therefeemand Q S the basis for the alleged exemption. Any violation of Section 7MIS by anyI'S q applicant fora permit subjects the appiicantto a civil penalty a net ore than TCII%TURFS subjectsmOUTLH live hundred dor ars of NEW ELFf_7R TYI'ECONSIitUC'1'ION 1,as owner of (S property,or my employees with wages as their sole compensation,will do the work and the stmeture at not Intended or offerN(or S p sale(Sec.70K Business and Professions Code:The Contractors LicenseLaw L/j $ docs not apply to an owner of property who Wilds or improves they rtd - OCCGROUI' RFS.UNTfS CC whodon chworkhi tforthwghhisuwnemploye 3'providedthat such Improvements are not Intended or offered for sale.If,however,the building or TOTAL: improvement b sold within one yeamf compladort the owner-W Iderwlll have not provingthat he did not build or Improve(orpurpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE ntractors to romtruct the project(See 7006,Business and Professions Cade: The Contractor's License law does not apply to an owner ed property who ALTER-DRAIN&VENT-WATER(EA) Wilds or Improves thereon,and who contracts for such pWjeM with a FEE SUMMARY cq�t�aOmit)licensed pursuant to the Contractor's License Law. BACKFLOWPROTECT.DEVICE LJ I am exempt under See. B&P C for this reasonOUTSIDE FEES DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_ Owner Date RECEIPT X WORKMAN COMPENSATION DECLARATION FIX.NRF_S PER TRAP SCHOOL TAX Y_ N_ F11 hereby affirm that I have a certificate of consent to self-Insure,ora RECEIPT X .AlflcatoofWorkers'Compematton Wurance ora mnited copy thereof(Sec. GAS EA.SYSTEM-11NCA OUTLETS PARK FTE Y N 3800,M.)C.) RECEIPT M CoPollcy n GAS EA.SYSTEM-OVER 6(EA) BUI LDING DIV]SION FE ES Y eniBed copy is filed hereby the cid. GREASE/WDUSIRL WASTE WTFRCEI'TOR PLANGHEGIC FEE Cenlled copy u filed with the city Inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SEINER-SANITARY-STORM EA 200FT Dat¢ Receipt# (Phis section need not be completed I the permit Is for one hundred dollars ($100),eless.) WATER HEATER W/VENT/F].EGTR ENERGY FEE Y_ N_ I artily bm that In the paAarmanceof the work forwhlch this permit Laed, 1 shall not employ any person In any manner as as to become subject to the WATERSYSTDI/TREATING workers'Compenaalon Laws of C.I fomla.Data PAID Z Z Applicant NEW RES[DPNIIAL I'LMB. SQ.FT. Date Revel t# Z NOTICE TO APPLICANT:If,after raking t his Cenllcam of Emrnptlan,you Oshould become subject to the Worken''Compematlan provisions of the Labor TOTAL: w Code,you must forthwith comply with such provisions orthis permit shall W BUILDING FEE .C27 W j deemed revoked. W F3 CONSTRUCTION LENDING AGENCY SEISMIC FEE a CL Ihereby affirm that there Is a comtmction lending agency for the perform ToiAl: ELECTRIC FEE 7 Z anre.f the workfn-whichthat permit is Lssued(Sec.3097,Civ.C.) PLUMBING FEE 02 Lenders Name LL F IendeexAddreaa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE O W Ianlfythat l have read that application and state that the above Information a evormct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID: mI.tingtobulldingcsmmmtion,and Wrebyauthorimrepmentativesofthat N city to entero the above-mantloud forW inspection ALTERORADDTOMECH. F z tY la°" keep Ire purposes. Date Receipt# (We)egree to ave,indemnify and keep harrtdess theCity of Cupertino AIR HANDLING UNIT(TO 10,000 CFM) V aga1mt11ablBtln,I nsequec"of h expanses whkh mayln anywayattmc SUBTOTAL: against al CI I nsryue "of the ting of this permit. AiG11' 3 7�-/-��—�/— AIRHANDLINC UNIT(OVER 10.000CIM) CONSTRUCTION TAX Sigmturcof Applicant/Contractor rr..ra� / IXHAUSTIIOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS ATERIALSDISCLOSURE Will the applicant or future buRding occupant store or handle hazardous HEATING UNIT(TO 100,000 BM Date Reeel t# material as defined by the Cupertino Municipal Code,Chapter 9.12,and the - T�a Iiealth and Safety Code Section 25532(s)7 HEATING UMT(OVER 100,000 BTU) TOTAL: 8 ❑Yes N No Will the applicant or future building occupant use eguipAent ordevices VENTILATION FAN(SINGLE REBID) IS �aDATE which emit hav A]oua air contaminants as defined by the Bay Area Air �!�/� Quality Management District? BOILER-COMP OHPOR 100,000 BTU) 4Ycs ❑❑No JUL oaf have read the bazarclous materials requirements under Chapter 8.95 of BOILER-COMP(OVFR 103,000 BIL) rw the California Health&Safety Code,Stolons 25505,25533 and 25530. 1 understand that if the building does not currently have a tenant,that it k my NEW RESIDENTIAL MECH. SQ.FT. Cs1 atresponsibility to notify the occupant of the requirements which must be met 711'I(I]I prio to'ssuancea nifateo(Oc ancy. -�raa�a root 1 .gen Data TOTAL: ISSUED BY; "✓F OFFICE COPY