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22110 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Build[. Pmj.a Identification PERMITNO, Building Address: j� 22110 �/"1 aY 0 ^'' 5N 7- WA006 6 3d CITYOFCUPERTINO-BUILDING DIVISION Cont'de sNamer Lic.No: APPLICATION / PERMIT BUILDING-E1.ECTRICAL.PLUMBINGMECIIANICAL CATEGORY CONTROL N Arch tea/Engleseer: Lie.No: QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO Address: PERNBTISSUANCE �7] ❑ ❑ O LICENSED CONTRACTOR'S DECLARATION L9 I hereby affirm that l am licensed under provisions of Chapter 9(concmenc- APPLIANCE-S-RESIDENTIAL JOB DESCRBT[ON ingwith Section 7000)of DIVIslon3oflhelE.amssand ProfessionsCode,and my ��� lice..]Class ]force and Afect. PANELS I -�C �'�� License Claes Lic.p L. Data Contractor ARCH ITECPS DECLARATION 201-1000AMPS a0 Z t understand eny plans slot be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA 5/SQ.FT. O �j Licensed Professional SIGNS ELECTRICAL 6 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSCOf Iherebyo(firm thatI am exempt from the Contraaorb License Law for the O, following reason.(Secttor7m1.5,Busmessand ProfessionsCude:Anyeltyor K 1'� countywhichnquirnapermittocomtruaaltegimpmve,demollsh,ormpair TEMP.MUTER OR POLE INST. GE .r any structure prior to its Issuance,also regulons the applicant for such permit to c6 0`U file a signed statement that he Is licensed pursuant to the provisions of the POWER DEVICES gypP.(. Contractor's License Law(Chapter 9(commencing with Section 7000)ofDivi- F�OQ sion3 ofthe Business and ProfesslonsCode)orthat he 6 exemptthercfromand SWWiMING POOL ELECTRIC VALUATION $ the basis for the alleged exemption. Any violation of Seaton 70315 by any OUTLETS SWITCHESFECIVRES ©� W ,pJ applicant fora permit subjectatheapplicant tea civil penalty snot nnrethar, c. o five hundred dollars(SSOB). NEW RESIDENTIAL ELECTR ❑i,as owner of the property,or my employees with wages as their sole `"Q''Pf. STORIPS TYPE CONSTRUCTION compensation,wW dothe work andthe structure is not intended or offered for $ ❑ ...(Set.7044,Business and Professions Code:The Contractor's License Law �$$ does not apply to an owner ofproperty who Wilds or improves thereon,and who doessuchworkhimseiforthrough his own employees,provided that such OCCGROUP AFS.UNTTS improvements are not Intended oroffend for sale.If,however,the building or TOTAL: Improvement issold withinoneyearofcomplMi n,theowner-bu0derwill have thl,Jprrden of proving that he did net build or improve for purpose ofsale.). QTy, PLUMBING PERMIT FEE pip ZDNh—ApN LI I,as no,of the property,am exclusively contracting with licensedPERMIT ISSUANCE to construct the project(Sec.704 Business and Pro(esslom Code: �I The Contractor's License law as napply to an owner a property who ALTER-DRAIN VENT WATER(EA) Wilds or Improvse thereon, and who contracts for such pRojeas with a FEE SUMMARY IaoKsexempt under Snt to the Comraaw'.Llmnx law. BACK FLAW PROTECT.DEVICE 1 am am)H unser sec. B&P C for Mb reason - 121�TSEDF FEES Owner ex ate S DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y_ N_ S 4 CM 1PFNSAT DECLARATION RFLEQTN ❑i hereby affirm that I rt a ren seFD( to of consent to self-Insure,or TURES PER TRAP SCI 1001.TAX Y N certificateofWorkers'Cimpe tlonlros anceoracertifkdropythereof(Sec. RECEIPTY 3800,Lab C.) GAS EA.SYSTEM-1 LNCAOUTLETS PARK Ia Y N Poli Go n CAS EA.SYS'T'EM-OVER4(EA) DING DIV Y BUILDING DIVISION PEES Certified copy Is hereby famished. ❑CerilOed copy bfiled with the city Inspection division GREASE/INDU5IRL WASTE INTERCEPTOR PLANCHECK FEE CERTIFICATE OF EREMITION FROM WORKLRV GREASE TRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Rem t# (fhiasee.) need nor be completed tithe permit Is(or one hundred dollars (51I cumlyth WATER HEATER W/VENT/ELECTR ENERGY FEE Y N Icertl(ythat in the performance of the work for which this permit is issued, — 1 shall not employ any person in any manner so da to become subject to the WATER SYSTEM/TREATING O Workers Compensation Laws of California.Date PAID Z NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FT. Date ReC i t# should become subRa to the Workers'Compertsst[on provisions of the Labor TOTAL: CC N Code,you must forthwith comply with such provisions or this permit shall be BUIL IN PEE .0 9 deeed voked. LU mreO CONSTRUCTION LENDING AGENCY SEISMIC FEE I hereby affirm that there Is a construction lend Ing agency for the perform- TOTAL ELECTRIC FEE Z arm of the work for which this permit is Issued(See30 Y/,Civ.C.) O O larders Name PLUMBING FEE IL F Lender'sAddersa QTY. MECHANICAL PERMIT FEE O W I cemfythat l have read thboppecaHorand tatethattheaboveinformatton MECHANICAL FEB CL isc'ormes.l egree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID: >_ N relating to but[ding construction,and hereby authorize representatives of (— Z city to enter u Pon the above_mentloned property for inspection Ell ER rposes. ALTOR ADDTO MECH.roDate Rxei t# V — (We)agree to save,indemnify an d keep harass the City of Cu proton P ago Inst liabilities,judgrcents,costs and expenses which may In any way accrue AIA HA NDLI NG UNIT(TO 10,000 CFM) SUBTOTAL: against d£i Inco ence ofsha.granting of this permit. AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX Igmtureof Appliant/ ntraaor pate `s IXHAUSIIIOOD(W/DUCT) CONSTRUCTION TAX PAID: HA OUSM ALSDISCLOSURE Will the appllant or wee build) pant sore or handle hazardous HEATING UNIT CFO 100,000 BTU) Date RCCCI t# mxterialasdeMed bythe uperilnoM tips,Code,Chapter 9.12,and the - HealthandSafetyCodeSection2 32(a)? HEATING UNIT(OVER 100,000 BTL!) TOTAL: Yes ri No Will the applicant or future building occupant use equipment or devices VENIILATION FAN(SINGLE RFSID) ISS(�AIV� ATE which emit hazardous air contaminants as defined by the Bay Area Air �Y'� r� Quality Maragement District? BOILER-COMP OTB'OR 100,000 BTU) 4 Yes No L have read the haze ous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) 1F p 'IOQi the Glifomla Health&Safety Code,Sections 25505,25533 and 25534. I F N Is7t!1 understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. raponsibillty to rally the occupant of the requirements which must be craft pAs,' rsa� prior to issuance of a (Bate ofira sty. �0��U@ W th1 1 �^I scar authorize ag Date _ TOTAL: ISSUED BY: OFFICE COPY