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22246 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY Building Project Identification - PERMITNO. B°IdingAddruss22246 \661 co cnQvs A�Ea neva ams: - one: lib E CITY OF CUPERTINO-BUILDING DIVISION Comeaat.e.N.me: m.No: APPLICATION /PERMIT b III Archltett Epglnesr. LR Lk.No: BUILDING-ELECTRICALPLUMBING-MDCHANICAL CATEGORY CONTROL C_---a rl BUILDING PERMIT INFO (� QTY ELECTRIC PERMIT FEE Address: s-z -q( PERMITISSUANCE LICENSED CONTRACTOR'S DECLARATION I hereby affinnthat l am licensed under provisions ofChapter9(mmmert APPLIANCESRFSIDENTIAL JOB DESCRIPTION ingwith Settlon700Bof Dlvlston3 ofthe Businessand ProfessionsCode,and my r license lain fun m and effect. 2^ PANELS - t 1 ' `• ,4 License Claes ._LICc -J 1 �q C1 •`��—yLLC v v A Date ContractorIII TO 200 AMPS ARCHITECTS DECLARATION M14"AMPS gz I understand my plans m shall be used u public renls. OVER1000AMPS SQ.FT.FLOOR AREA $/SQ.FT. 19 Licensed Professtonsl SIGNSELECTRICAL OWNER-BUILDER DECLARATION SPECIALCIiCUIT/MLSC D IN Z.�4 I hereby that l am e.empt fromthe Contractor.LloceseLaw fm the following reason.(Section 7031.5,Business and Professions Code:Any city or 11 O j. TEMP.METER ORPOLE INST. p countywhichrequlmaper ttommtmat,alter,lmpmwde=l4h,orrepalr qOTER an ystrctmmpriortnitsissuance,aLwmquimtheappnantfmsuchpermltto POWER DEVICES 1 DATE �a file a signed statement that he b Ikensed pursuant to the provisions of the COnlrettOre License Law(Chapter 9(commencing with Section 1000).1� Dlvl- ALUA'DON�5 sion3 ofthellusiness and ProfenlonsCode)orlhat hebexempt therefromand SWI.IMING POOL ELECTRIC < the basis for the alleged exemption. Any violation of Section 70315 by any UTLE'ISSWITCHESFIX'1'UftES ( • (O/ ' D (/]f) U/1 m applicant fora permit subjeaethe applicant to a civil penalty of not orethan l five hundred dollars NEW RESIDENTIAL RLELTR SQFr. STORIES TYPE CONSTRUCTION �n ❑I,as owner of the property,or my employees with wages as their sole C compensation,will d o the work,and the structure Is not intended or offered for 5 M sale(See 7044 Ruelneuand Professions Code:The Contractors License Law does not apply to an owner of property who builds or Improves thereon,and IXC.GROUP RFS UNITS who does.uch work himselforthrough hlsown employees,provided that such '� Improvements are nm intended oroffered fmsale.It however thebuilding m TOTAL: Improvemenlbsold withinoneyearofmmplel Nthenwnerbullderwni have tla]Iurden of proving that hedid not build or Improve for purpose oftale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE MN u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE crntrectom to construct the project(Sec.7014,Business and Pro(eseloru Code: The Contractor's Llmnse Law does not apply to an owner M property who ALTER-DRAIN VENT-WATER(EA) bunds or Improves Merton, and who contracts for such pwjects with a FEE SUMMARY c75.0mW Bcamed Pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE IJ I am exempt under Sec B k P C for this reason DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N Owner Date . REC©PrM WOm certificate RKMAN COMPE45ATION DECLARATION I FIX.flR2FS PER TRAP ` SCI;OOL TAX Y N Ell hereby affirthat I have a of consent to self-Insure,m a RECEIPT M cedifiuteofWorkers'C.peruatlonlruurancemamrtifledmpythemof(Sec, GAS EA.SYSTEM-]INCA OUTLETS PARK FEE Y N 3800,Lab C.)- _ \ 66 RECEIPT_Polity M CAS EA.SYSTEM-0VER d(EA) Cam v - BUILDINGDIVISIONFEES CertNe ropy b hereby(umbhed. Inspection division. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE ed copy b(lied with the city CERTIFICATE OF O(EMPTION FROM WORKERS' GREASE-TRAP PAID COMPENSATION INSURANCE SEWER -sroRM PA.200Fr. Date Recei [ri (Thlssealon need not be completed Bthepermit b fmone hundred dollars (f100nnify that.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N D I ori that Nthe perfomanmaf the comicfor wMch this permit Is Weed, I shall not employ any person In any manner so as to become abject to the WATER SYSTPM/TRGTING Workeri Compensation Laws of California.Date PAID ZZ Applicant NEW RESIDENTIAL FILMS SQFC. Date Recei t# Z O NOTICETO APPLICANT:ILaBer making thin Certificate of Exemption,you 7. should become subject to the Workers'Compensation provisions of the Labor TOTAL: 0 N Cie,you moat fortbwlth comply with such provisions or this permit shall be BUILDING LU > deemed revoked. CL CONSTRUCTION LENDING AGENCY SEISMIC FEE /• Iherebyaffi that there b a construction lending agency for the perform ELECTRIC FEE Z ance of the workfor which this permit is baued(Sec 3097,Civ.C.) TOTAL: ( ' V O Lander:Name PLUMBING FEE tQ7 LL 1— Lendm:Addm. QTY. MECHANICAL PERMIT FTE MECHANICAL FEE O W le rtifythatl hav madthbappbmtWnandstalethattheaboveinformation CL b oomes.I agree to complywith all city and county ordinances and state laws PERMTTIS5UANCE FEES PAID: >- N mlatingwinuilding mmtructlon,end Mrcby.tAlumlze representativesoflhis - (_ city to enter upon the above-mentioned property fm impectlon purpose.. ALTER OR ADD I[)MECH. Z (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt# V against lbbilltke,judgments,costs and expe...whkhnu Inanymyaceme AIRHANDUNGUNUCT010,000CIM) SUBTOTAL: III 111.70 ainsl said City In mniqueree of the grant ape.-3 CONSTRUCTION TAX 1'� AIR HANDLING UNIT I BBDO CFM) lure of Apphunt/Contractor 1 Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or hand Is hazardous HEATING UNIT HO 100,000 BTU) Date Re iii t# material as defined by the Cupertino Municipal Code,Chapter 912,and the a Health and Safety Cade Section 25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL: (rr ❑ Yes la�-,1 No Will the havand cat ar(u oat building occupantd by the Bay Areat devlms VENTILATION FAN(SINGLE RESID) t$$Ljt\�I DATE which emithazardousabrict?contaminants by the Ray Area Air -• Quality Management District? BOILER-COMP MIT OR 100,000 BTU) , 4 Yes n Na BOILER-COMP(OVER 100.000 BTU an 61"'1 have readthel,. ousmaterials requirements under Chapter 6.95 of UL the Caiifomla Ilealth k SafetyCode,Sectlons 25505,25533 and 25534. I undenuxecithaI lithe building does not currently haveatenanl,that it b my NEW RESIDENTIAL MECH. S2, responsibility to notify the occupant of the mquberamm which at be met — Will prior to boua lice ma Certificate of Occupancy. - Owneror authorized agent - Date ISSUED BY:4 1I d 1 V TOTAL: OFFICE COPY