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22285 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —'USE BALL POINT PEN ONLY Building Protect Identification PERMIT NO. Budd Ing Add rens: O C .22 os' Y C�i92WOPD Gi_ _ of ane: one: J RQ I Woz-rAS }fr-6/6g CITY OF CUPERTINO-BUILDING DIVISION f 1 . Ge^a` JJ[kj Lie.No APPLICATION /PERMIT � ' BLnDINC ELECTRICALMLTMBINC-MECHANICAL CATEGORY CONTROL M Architect/Engineer. Lk.No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address PERMITISUANCE ( GO ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION Ix IherebyaRirm that l am tensed under provision.(Chapter9(comment. APPLIANCESRESIDENT1AL JOB DESCRIPTION Ingwlth Sed)on7DOD)of Dlvlclon3ofthe Budruresand Pmfesdons Code,and my time.1.In full force and effect. PANELS Llan.Class If t Date Contractor —UP TO 200ANGN ARCHITECT'S DECLARATION 101-IODOAMPS a0 t I understand my plans shall be used as public records. OVER 1000AMPS ?L o Licensed Professional I SIGNS ELECTRICAL J S <<� OWNEReBUILDER DECLARATION LCIRCUIT/MISC ' ® � y F[ ZE, owingrssue.(edd..731.5,Bxempt(romthe ContractorsLlan.Law(it the c /U R l following recon.ircoaOn 7m1S,Butlneu and Profmimu Code:h o city or TEMP.MFTELR ORPOLE INST. pEL oountywhlch requlmaperrtdttoanstwct,ellen improve,demolhh,orrepalr q any signed palercolts Issuance,also sed pursuant thecam roved.orsuch of t e POWER DEVICES fees a signed statement that M b licensed pursuant to the provlsloru of the Q6 0 u, Con stem'.Lice.law(Chapter 9(commencing with Section 7000)of Divi. SWIMMING POOL ELECTRIC 30 don3 of thegusinemend Professions Code)arthat hehexempt thercfromand G the bash for the alleged exemption. Any violation of Section 7MIS by any OUILETSSWITCHESTI%TURES VALUATION applicant fora permit subj d.the applicant to a ciAl pealty of not..thao five hundred dollars($500). NEW RESIDENTIAL ELECTR rI 1,a9 owner of the property,or my employees with wages as their sole SQ'T' SIORIFB TYPE CONSTRUCTION compensation,will do the work.and the structure is not Intended or offered for sale(Sec.7064,Business and Profa shme Code:The Contractors License Iaw dose net apply to an owner of property who builds or improves thereon,and - EE who docs such work himseQathrough hlsown employees,provided that webOCC.GROUP RFS.UMTS Improvementsre anot intended proffered forests.If,however,theWilding or TOTAL: 7a C P Improvement bsald withinoneyearotcomple Wb theowner-bullderwlll have en of provlmgihat he dW nit build or improve(or puryoa o(ule,). QTY, PLUMBING PERMIT FEE - FLOOD ZONE APN F.owner of the property,em exdueively antncting with Ilrensed PERMIT ISSUANCE ro ra on to arutmct the projM(Sec 7044,Business and Professions Code: Contnctors Llanse Taw use nit apply to an owner of property who ALTER-DRAIN k VFM-WATER(EA) build.or Improvre Improves thereon,and who contracts ntfee such pgejects with e c gash r(s)Romead pursuant to the Contractor.License Law. FEE SUMMARY LI I am exempt under Sec. B k P C for this reason BACK FLOW PROTECT.DEVICE Owner Data DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_ RECEIPT WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y N QI hereby aHkm that I have a certi0ate of consent to self-hesure,or e RECEIPT anlflabC.Worken'CamperuaHon lnsunna as artlfiM spy thereo(l5ec. GAS EA.SYSTEM-1 INCAOUTLETS PARK FEE Y_ N_ 3800, N C.) RECEIPT M Coiiry p GAS EA.SYSTEM-OVER 4(EA) Cany BUILDING DIVISION FEES ffMified copy is hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE Certified copy h filed with the city Iospeotion division. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA p0p1. Date Recei f# fChis.dion need not be completed If/he permit isfor one hundred dollars (410D)aless.) performance HEATER W/VENT/EL[CTR ENERGY FEE Y_ N_ I certify that In the perfounce of the work for which this permit is issued, I shall nor employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING worker:Compensation Law.of California.Date PAID O Z Applicant NEW RF9DENTIAL PLMB. SQ.FT. Date Recei t# Z 0 NOTICE TO APPLICANT:ILaher making this Certlfkateof Exemption,you should become subject to the WorkerCompereatlon provisions of the Labor TOTAL: CW Code,you moat forthwith comply wiflawch provhlons orthh permit shall be BUILDING W j deemed revoked. a O CONSTRUCTION LENDING AGENCY SEISMIC FEE Ihembyafflrmth h hat there h a ansHuctlon lending agency for the perform TOTAL: ELECTRIC FEE a 0 sure of the workfor which this permit eucd(Sec.3097,Civ.C.) Lender:Name PLUMBING FEE LL ~ LendereAdd.. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE O W haIcertifythatl have read thhappliatlonand statethattheabove information 1 rrect.I agreeto complywlth act cityand aunty ordinances and state laws PERMITL%UANCE FEES PAID: CO relating tobulldimganstroctlon,and hereby.whodn . mprentativeeo(thh F Z city to enter upon the above-nemtiored property for Inspection purposes. ALTERORADDTOMECH. Dale Recti t# z (We)agree to save,Indemnify an d keep harm1m the City of Cu pertleo against lhbil lee,judgments,"a and expenses which may in any way accrue AIR HANDLING UNIT ITO 10,000 GEM) SUBTOTAL: against said Ity In cunsrquence of theantln this permit. AIR HANDLING UNIT(OVER IR000CFM) CONSTRUCTION TAX 6,1!11 CONSTRUCTION TAX PAID: i of Applin Contractor Date FX}iAl15T HOOD(W/DUCT) HA RDOUSMAego ALS DISCLOtstomoSURE Will the apleed b or future ruin Municipal Code, h pter9 Zanhazardous HEATING UNIT(TO 100,000 BTU) Date RBCei [N matedal'as defined by a SCumi 255 Municipal Code,Chapter 9.17,end the Health and Safety Code Section 75531007 HEATING UNIT(OVER 100,000 BTU) TOTAL: ov n Yes M No Rl the applicant orfuum,building occupant use equipment or devices VENTILATION FAN(SINGLE REST ISSUANCE DATE which emit hazardous air contaminants as defined by the Bay Area AU Quality Management District? BOfLER-COMP PHPOR 100,000 BTM 4Yea have read the fiaaawousomaterials requirements under Chapter 6.95 of BORER-COMP(OVER 100,000 BTU) the California Health k Safety Code,Sections 25MS,25533 and 15534.I understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIALJUN 1 �]MECH. SQ.Ff v'"�-° re` 991 responsibility to notify the occupant of the requirements which resat be met ' prior to Issuance of a Certificate of Occupancy. -T-a� Owner or authorized agent Date TOTAL: ISUEDBY(•V(/�� OFFICE COPY