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22674 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification - PI]EMIT NO. Building Address: 22674 D /0 9- ,dam ��/®: eine: one: - A s CITY OF CUPERTINO-BUILDING DIVISION • °"trail°r'eName: Uc.No: APPLICATION I PERMIT `^' �� '✓ BUILDING-ELECTRICAUPLUMBINGMECHANICAL CATEGORY CONTROL X Architect/Engineer. Lk.No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: PERMIT ISSUANCEfSY 1:1 ❑ LIC ENS EDCONTMe, DECLARATION �{ Thereby affirm,that lam Bceneext d underprovhlans olChapler9(commsnc APPLIANCES-RESIDENTIAL 168 DESCRIPTION Ingwlth Sedlon7000)ot Division 3 ofthe Buslnessand ProfessmaCpde,and my License Isle(uB form and fed. PAFIpS License Claes Lk.X� Date contractor ?�ec.� UP TO 2DDANU AR shall DE pubIle IO OVERT201.1" � OZ Iundentand my plain shag be used apublic records OVERIWOAMI'S SQ.Fr.FLOOR AREA S/SQ.FT. Owe �j Licensed Professional SIGNS ELECTRICAL - 1 OWNER-BUILDER DECLARATION $(+ECULCIRC TJN p, Ihereby affirmtlut l am exempt lromthe Contractor's License law for the Z following reason. 7R715,Business and Professions Code:Anydtyor 0. F TEMP.MECQt OR OLE INSI. I. I P rauntywhlch rcqulress perroft to auancemx,mquirsathnatruct,alter,ImpnvgdennWh,orrepao q� a anyswdure priortolts Wuance,almmpslms/heappBant for such permit to ppWER DEVI/ - , ,' r f,.� � Y`� "^ r—� D 6 O U file a signed statement that he h licensed pursuant to the provlslom of the EOS 9(commencing G Cmiredors License law(Chapmrwith Secdcurt 7000fDivi. SWAthfIfYG POOL ELECTRIC saunabasis for the lle e d exemption. Any viohat lation f exempt therelmmany 1 VALUATION �- �5mp'+ the tads for the alleged exemption. Any violation of Section 70315 by any O[17LE7SSWITCfIESFl 1 O© (W p5 app hundred doll.. $500),b lheappllnnt toe dull pemltyo(nd more than ( t $ five hundred dollen(5500), NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPECONSTRUCTION E3I,as owner at the property,or my employees with wages as their sole �Za compensation,wOldothework,andthestmdum Ism intended or offered for O sale(Sec.7614 BusNea and Profealom Code:The Contractors License Law jS$ does notapplytoan owner of property who bullds orlmpr°vesthereon,and OCC.GROUP RFS.UNITS whodoeasuchwork himself orthrough heownemployees,provided thatsuch _ improvements are net Intended orofferd!orale.IQ h°wever,thebuilding or TOTAL. Improvement h ski within oneyearofcompletlon,theowner-bullderwill have t rdenof provingM ithat did not build or Improve for Purpose°feele.). QTY. PLUMBING PERMIT FEE FLOOD ZONE MIN LI,as owner of the property,am exclusively contracting with Licensed PERMIT ISSUANCE. contractors to construct the pm)ect(Sec 7014,Business and Professions Code: The Contndoh License Law does not apply to an owner of property who ALTER DRAIN 4c VENT, WATER(EAT . builds or Improves thenen,and who contnm for such p(ojeds with a FEE SUMMARY abador(a)licensed pursuant to the Contndora Limnse I. BACK FLOW PROTECT.DEVICE LI I am exempt under Sec reason B k P C for this on DRAINS FLOOR IT ROOF,AREA,COND. SANITARY Y N_, • Owner Date RECEIVE N WORKMAN COMPENSATION DECLARATION enFD(NRFS PER TRAP SCHOOL TAX Y N C31 hereby affirm that 7 have a Trtme of consent to self-houre,ora RECEIPT N MOD,le o(Worken'Campesuatlwtaurance ma certlfkd mpythpythereo!(Sec. CAS EA.SYSTEM-11NG4 OUTLETS PARKFPE Y N Polis Y lab CJ RECEPT M Policy GAS EA.SYSTEM-OVER 4(EA) Com any BUILDING DIVISION FEES ECertified copy le hereby furnished. CREASEANDUSTRL WASTE INTERCEPTOR PLANCHECKFEE 'TSQCertIBed copy h(fled withh the city la)sectlon division.f'—'' CERTIFICATE OF OfEMPFION FROM WOR KERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWER-SANITARY S'PDRM EA 300Fi Date RCCei [q (This section need net be completed If the permit b for one hundreddollars ($100cemlea) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N I By, m that In the perlounreo/the winNWsew k for s permit is ed, 1 shall not employ any person In any mannerso as to become subject to the WATER SYSTEM/TREATING Worken'Compensation Laws of California. Date PAID Z TIC Z NOE O NOlicant APPLICANT.If,after making ththisCertl(Inte of Exem)xlan,you NEW RESIDENTIAL"B. SQFT. Date Recei t# Fshould become subject to the Workers'Compensation provisions of the Labor TOTAL: c y Cde,ymmust/onhwllhmmplywlthsuchpmWlomorthbpermltshallbeI N LU > deemed revoked. - CONSTRUCTION LENDING AGENCY SEISMIC FEE d I hereby atfirmthat there h a construction lending agency for the perform ELECTRIC FEE Zanceofthe work for which tph permit is issued(Sec.3097,C1v,C.) TOTAL: O O Landers Name A I PLUMBING FEE F Lender's Address QTY. MECHANICAL PERMIT FEE O W ce I rtilythat I have read thbappllentlonand datelhalthe above Information MECHANICAL FEE S hcorvdIR .Iagreetocomplywlthallcityandcountyordinancesandmatehevs PMITISSUANCE FEES PAID: ). W relating to building cone rodlon,and hereby authorize representativesofthis I.- city to enter upon the abovcmentloned property for Inspection purposes. ALTER OR ADD TO MFiCH. Z- (We)agree to ave,Indemnify an it krep harmless the City of Cupertino Date Receipt# V against liabilities,ydgmente,cosmand expenses which may In anywayacnue AIR HANDLING UNR(T010,000 CFM) SUBTOTAL' against uid City In consequence of the granting of this permit. AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX Signature of Applicant/Contractor Date FXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the appBant or future bulldingo ant sloe or handle havrdous. HEATING UNIT(TO 100,000 BTU) Date Recei t# materhl as defined bytM Cupertl Mu ICode apler9.17,and the Heallhand Safety Cod to a - HFATINC UNIT(OVER 100,000 BTU) TOTAL: yes No �Viil the appllmn s er to •11 ing sus a preen rdevices VENTILATION PAN(SINGLE RESID) ISS)nIApTCE DATE which emit hawrdo i contaminants as defined by the Bay Area Air ���'1�/��l. Qua lity Me rugemcnt Distrid7 BOILER-COMP OHP OR 100,000 BTU) RDl ave read the earth It our mach to reons 25505,25533 and Chapter 6.95 of IIOILFR-COMP(OVpT](10,000 BTU) the California HealthkSafety Code,Sectiam currently I tandt,that 1 understand that lithe gdoes not curtenlly haveatenanL that lthmy NEW RESIDENTIAL MECH. SQ.FT. responsibility to not% a pant of the requ menti which must be mM ptlor race of to f 0 _ —i+61,f``N1`try'jeieFsYaP�l/VN3�L.}'/' rauthmnzed agent / DateISSUEDBV ,a�� TOTAL: — �� � ��� OFFICE COPY