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22969 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PERMIT NO. Building Address: 22969 z o •�� A uva G-r-: w re ame: one: p g/t�ilC� MkTOD�B 755.14"1 CITY OFCUPERTINO-BUILDING DIVISION Copttwctor'.Name: S 1s .. �.No: I APPLICATION I PERMIT •�,�� /-• BUILDING-ELECTRICAL•PLUMBING-MECHANICAL CATEGORY CONTROL N Architect/Frglneer: Lie.No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: QTY •� ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION L/(� I hereby affirm that l am Remand under provblonsof Chapter 9(commenc APPLIANCES-RESIDENTIAL he DFSCRT MON ingwith Srdion7000)of Dlvislon3 ofthe0uameiand Profeskone Code,and my - Ilcense Is in full farce and effect. PANELS F' License Che Lontr ANS �Oa. - Cle, # Date r UP TO 2DOAHM ARCHITECTS DECLARATION 201-1000 AMPS re l' {understand my phos shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA E/`.Q,Fr. O dLicensed Professional SIGNSELECTRICAL res 6 OWNER-BUILDER DECLARATION a SPECIAL CIRCUIT/MLSC 7 L., following reason. (Sect I.31,5,Bxempt from the d Profctorb Llcemo Law dt the ppp =ntywhkhmquimstioe7 tt,Bualnemand Pimp oneemle hydtyor countywhlch requlresa pemdt tomnstruct,alter,lmpmve,demaWh,or repair TFMP.METER OR POLE INST. anystmdunprlortoltslswance,alsorequireslheeppllmntforsuchpermltto POWERDEV ICES p F ilka signed statement that he h licensed pursuant to the provisions of the - Contractor's License Law(Chapter 9(commencing with Sedlon 7")of Divi- 0S VALUATION � elon3oftheBuknedeandPro(eelonsCodOmthat he is exempt therefromandSWIMMING POOL ELECTRIC the basin for the alleged exemption. Any violation of Section 70313 by any 6 0 od p appRcantfora permit subjects theappllcant to a civil penalty of not nom than OUTLETSSWITCHESEXI'URES `r Ove hundred co eroftheollars W). NEW RESIDENTIAL ELECTR SQFT. 9['ORIES TYPECONSTRUCTION �n ❑I,asownerof theproperty,orhe employees inwithwages r their dole zQ compensation,70K Busio the ness ess andwork,and thesC de;T e cindmdot ed m offeevoumLaw ' F d for R doe not 7674,to alnowand Prooperty who builds Contractors License law $ does not apply loan imierorthrou h who nempayees,p provided em,that and who dansuch nts amwork Mmsendedorwghhhnw own II cwe eovicbuiIdeuch L� ' �0l1 RIS.UNITS improvement issold lnlendneyear fcompered reale.the owevebuilde lldingw pL, l , 71UB Improvement beold wlthinoneyeamfcompldion,rias owner-bullderwlllhave � ' tFiilj�srdeo of proving that he did not build or improve for purpose ofsale.). QTY. PLUMBING PE }7 _ APN LJ L as owner of the property,am exclusively contracting with licensedpp(MIT ISSUANCE o J Iv�,,,� centradom to cowtMd the project(Sec.7064,Business and Professions Code: The Cmaradmh License Law don not apply to an owner of property who builds or Improve thamoe, and who contracts for such ptojem with a ALTER-DRAIN&VEM�WA — crylt{dor(a)Ranmd pursuant to the Contractor's Llcenee Law. BAIX FLOW PROTECT.DEVICE' U MARY LI I am exempt under Sec. B k P C for this reason DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N� Owner Date RECEIPT WORKMAN MAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y N_ ❑I hereby affirm that I have a cedl0cate of consent to self-Insure,or a RECEIPT N certiflcale of Workers'Compensatlonlnsurance oracertilbd copy thereof(Esc. CAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N_ 1800,Lb C.) Policy any GAS EA.SYSTEM-OVER MAI E 7# Corledcopy herebytd. BUILDING ION FEES mcart10edcopy 0 fkd with the city IvpecTon division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWER- STORM-STORM EA.2o0FT. Date Rewi t# (Chlsudion need cad edcomplded Vito,permit ls(Drone hundred dollen (3100)ur Ines.) WATER HFATE{W/VENT/ELECTR ENERGY FEE Y N I certify that in the performance of the work for which this permit is blued, — I shall not employ any person In any manner m as to become subject to the WATER SYST}.-Y1/TREA7TNC Workeri Compeneatlon laws of Califomb.Date PAID ZZ Applicant NEW RESIDENTIAL PLMB. 9Q.FT. Date Retei t# O NOlicant APPLICANT:If,after nkking this Certificate of Exemption,you should become subjcd to the Workers'Compareartim provisions of the Labor TOTAL: W /Lode,you most forthwith comply with such provisions orlhh permit shall be W > deemed revoked. RLIJUDING FEE CONSTRUCTION LINDINC AGENCY SEISMIC FEE CL C Ihercbya(ttrmthat there is a construction lending agency for the perform ELECTRIC FEE Z ance of the workfor which this permit 6 inded(.&c.3W7,Civ.C.) TOTAL: - O O Landn'e Name PLUMBING FEE IL H Le.dcr'sAddreea QTY, MECHANICAL PERMIT FEE MECHANICAL FEE OCl) Icerilfylhatl have read lhisapplicalionand statelhatthe above information , & bmrrect.l agree tocompiy with all city and county ordinances and orate laws PERMITISSUANCE FEES PAID: >- relating tobuliding mnstaueBon,and herebyauthorhe representatives otthb F 2 city to enter upon the abovcmentloned property for inspection purposes. ALTER OR AUDIO MECH. Date ReCel t# (Na)agree to save,indemnify an d keep harmless the City of Cupertino P V agamithabiRthajudgmente,coke andexpe wh chmsyinsnywayacetue MRHANDUNGUMTCTOIO,000CFM) SUBTOTAL' a Id Cityln mnsryuence ofthe;Z of Permit qq�� AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX „A.%Y— CONSTRUCTION TAX PAID: mo App HAZA ontrador Date IXF1AlJ5T HOOD(W/DUCT) MA2A RDOUS MATERIALS UIS re or h Will the appllmnt or future building occupant store or handlehuardoua HEATING UMT(TO IOO,OW BT(/) material as defined by the Cupertino Mu oldpal Code,Chapter 9.12,and the Date ReCei t# Hes llh and Safety Cod rra.�Section 25532(a)7 HEATING UNIT(OVER 100,000 HIM TOTAL: Yes U No Wliltheapplicant or future building occupant use equipment or devices VEMILATION FAN(SINGLE RESID) ISSUANCE DATE which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District? BOILER-COMP OHP OR 100.O00 BTU) 1 Yea ❑No D have rcadtheh.rdOus ma !terials requirements under Chapter 6.95 of BOILER-COMP 100,000 BTL) J the Cellfornh Health&Safely Code,Sedlona 25505,25533 and 25516.1 J understand that if the building doesnol currently have a tenant,that it is my NEW RESIDINTIALMEO{. 5Q.FT NOV �� rmponslbitity to notify the occupant of the requirements which must be met 1 prior to issuance of a Certificate of Occupancy. CIT . V v'OF C 1rt� rI Owner or aulhorired agentDate ISSUEDBY - TOTAL: — OFFICE COPY