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22475 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY Building Protect Identification PERM]TNO. Bnilaing Addre„o f2. - 22475 "L 36 woopc3vcv � ane: p weans arse: CITY OF CUPERTINO-BUILDING DIVISION Conlrador'e Name: Lk.No: APPLICATION I PERMIT / f CLN/L CON U ON1,VC BUILDINGELFICTRICALPLUMBING-MECIIAMCAL CATEGORY CONTR)aLr Archlted/Engineer. Lie.Na eL.1 b0 DAi QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address 161 D — DrI'ERMITISSDANGE LICENSED WNTRACTOR'S DECLARATION�LICENSEDC NTRACTOR'S DECLARATION I hereby affirm that l am provisions licensed under of Chapter 9(commere APPLIANCES&RESIDENIIAL JOB DFSCRB'TION ingwith Scdion7000 vision 3ofthe Buslnessand ProfessiomCode,and my Ilcend lain to and effect. PAN©9 Llmnse Lk D Contractor ARCHITECTS DECLARATION 201-1000AMPS I understand my plan shall be used as public recordw OVER 1000 AMPS SQ.FT.FLOOR AREA _j/.SQ-Pf;" C° - L+ z3� U Licensed professional SIGNSELECTRICAL �6 OWNER-BUILDER DECLARATION S[+p-CULCIRCNT/MISC zF, � IherebyatRrce that l am exempt from the Contradoes License law for the Q following reason.(Section 7011.5,Business and Prolamines Code:Any city or F f� county which requires a permit to construct,alter,Improve,demolish,or repair TEMP.METER OR POLE INST. y�y any shvctu ,prior to its kwance,alwrtquims theapplicant for such permit to POWERDEVICES 61 f#w6 file a signed statement that he k licensed pursuant to the provisions of the O /'v ON 3u' . Contractors License Law(Chapter9 m (comencing with Section 7000)of DWI. SWIMMING POOL ELECTRIC VLp�L•U1AT( Alen 3 ofthe Businessand ProfessionsCode)orthat he k exempttherefermand 6.•77 the basis for the alleged exemption. Any violation of Scdlon 70312 by any OUTLETSSWI7'CI IFSFl fT,;;. applicant for a permit subjav the applicant to a doll penalty of no..the. O A five 1,as o er of the p0). ot',cT MRIES ® g CpNSIRIKTION ❑I,ae owner of the proparty,or my employers with wages as their eek NEW RESIDENTIAL ELECTR ' "'G compensation,will dothe work and thestrocture k noHntended or offend for /� [P� Omle(Sec 7064,Business and Protembns Code;Thu ContractoYe License Gw x. L E �$ does not apply to an owner of property who builds or improves lhereoA and ITS who doe,such work hlmselforthrough hlsawnemployeus,providedth tsuch I imp ovem.ets are not Intended oreffered for sale.If,however,the buildingor TOTAL: improvement b wld within one y.ar of<omplciloM the owner-W Ilder will have tFl eclan ofpmvingthai he did nor build orlmprove for purpose ofukJ. QTy, PLUMBING PERMIT rEKAFTpp u L As mune,of the property,am mi.,ively mntradl ,with acro. pERMpF ISSUANCE E contractors to coneumd the project(Sec.7044,Business and Professleu Code: L The Contractors License Law does one apply to An owner of property who ALTER-DRAIN k VENT•WATER fEA) Wilds or improves thereon,and who contracts far such projects with a W FEE SUMMARY cga(factor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE. I�l I Am exempt under Sec 0 k P C for this recon DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N� Owner Date RECEIPT WORKMAN COMPENSATION DECLARATION rpm SCI300L FAX Y N 01 hereby affirm that 1 have a cartiBaself-Inure, FIXTURES PER TRAP te of consent to or `G RECER T N ceAificateo(worken'Cempematien uuranceo,a Biedropythereef(Sec. GAS EA.SYSIFAI-1INCA OUTLETS PARK FEE Y N 3800,lab C.) Policy N CAS PA.SYSTEM-OVER 6(EA) RECEIPT N Com n BUILDING DIVISION FEES C ins py k(tiedwhereby tht ed. GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECKFEE Te rtI ied copy b Bled with the city Wptdbn dlvlelon. ] I r CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID'?-Lq-RI COMPENSATION INSURANCE SEWER-SAMTARY-STORM EA.200FK Date Recei t# ` eedlon need nu becompleted lithe permit isle,one hundred dollars l (51 I0)orlyth WATER HEATER W/VENT/ELECTR ENERGY FEE Y N (certify that in the person in an tmannerhe work w As to b this become b blued, I shall not employ any person In any manner eo u to berome aub)ed to the WATER SYSTEM/TREATINGWork.ri Compenution laws of California. Date PAID O Z Applicant C) NEW RESIDENTIAL PLMB. SQFT. Date Recel t# Z NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you Fshould become subject to the Workers'Compeuatlon provisions ofthe Labor TOTAL' 7--Code,you most forthwith comply with such provisions or this permit shall be Wdeemed revoked, B O 0. O CONSTRUCTION LENDING AGENCY SEISMIC FEEE t LE I hereby affirm that there i e construction Iagency for the perform, 7 Z ante of the work(orwhkhihh permit k Issued (Sec.(Sec.3097,CIv.CJ TOTAL: 6 ELECTRIC FEE Ot U O LendAe.Name PLUMBING FEE LL I- Lender's Address - QTY. MECHANICAL PERMIT FEE MECHANICAL FEG OW I cenifythat l haveread this application ami state thattheabewe information _ W ocomrd.IAgree to comply with.]] countyordlnance.edslate laws PERMITISSUANCE LW FEES PAID: } W relating to building construction,and hereby autharbe representatives of this F city to enter upon the above-mentioned property for impaction purposes. ALTERORADDTOMECH. \ Z Date Recei t# \\ (We)agree to Judgments, Indemnity and keep harmless the City of Cupertino Aga mt Bablllttry nconsiquancetof the expends whkhmay ln any wayamue AIR HANDLING UNIT G010,000 CFM) SUBTOTAL: agalutu Pty In cons uenre o(Me granting his pertnit. AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX Sig tore o(Appllcant/Contrac Date EXHAUSTHOOD(W/DICT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will theapplirant or future building occupant store or handle hazardous I MATING UNIT(TO 100,000 BTU) Date Receipt#- - [trial as defined by the Cupertino Municipal Code,Chapter 9.12,and the I ealth and Safety Code Section 25532(a)2 HEATING UNIT(OVER 100,000 BTU TOTAL. ❑Yes (�No Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE which cent baurdeus air contaminants as defined by the Bay Arca Air AI® Quality Management Dlstrici7 BOILER-COMP'pFN OR 100,000 BTU Yes (�No haves,eadihebazaidausmaterialsmquimr ntsunderChapler6.95of BOILER-COMP(OVER 100,D10 BTU) the California Health k Safety Code,Sections 25505,25533 and 25534.1 understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. responsibility to notify the occupant of the requirements which must be rrct � prior to Issuance of a Certificate ofOmpancy. R�j� &OE •-j\ (lt��J✓ Owner or autho cad agent Data - TOTAL: ISSUED BY OFFICE COPY