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22757 (2) APPLICANT TO FILL I//N�� INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY BuIt oAddiui�n Pro Identification f{/e'1 I 0 Y/ 1'FRA9 h22757 S OrrCITY OF CUPERTINO-BUILDING DIVISION ® C vmorsName: k.Nm APPLICATION / PERMIT BUILDINGdECTRICALPLUMBINGMECHAMCA CATEGORY CONTROL mhBect/Engircer. IY No: ��II,,�I ''`` Q ELECTRIC PERMIT FEE BUILDING PERMIT INFO Add D „y W �RA� PERNITISSUANCE ❑ ❑ ❑ LICENSECONTRACTOR'S DECLATION I hereby affirm that l am licensed under pmvbionsof Chapter 9(commere. APPLIANCESRES[DENTIAL BDESCRI['fION Ingwlth Seabn7000)ofdeffecn3ofthe Budnessandl4afesslonsCade,and �� Licensebecti and effect 3 PANELS l LI¢nev Claw_ LICI - Da4 ConlneoLM TO 2DOANIPS ARCHITECP SOD 1701-IW q�q�uuµPIyI O 1 understand my pbm shag be used u public a OVER 11X10 AMPS SQ.FT.FLOOR AREA S/SQ.FT. 'Fe y Fj Licensed Pmfenbrol SIGNS ELECTRICAL [— © I n' 6 OWNER-BUILDER DECLARATION SPECIAL CIACIIIT/MISC �' IlLT;q :� N 1.,�� IhertbyafOrmthatlamexemptlmnthe Contnctora Licence law far the - I // R,Q following reason.Section 7031,5,Businea and Prefessbro Code:Mynry or -_J LTJ RL t- TEMP.MEITR OR POLEINST.p .muntywhlchrNub apee towro d,a]4r,lmpmve,demolbh,ormpalr hp,5a ystmd mpni«tottsl ameaborequlmtheapphl ntf¢ucbpe wI'OY.'FR DEVICESOE6 Rle a dgned statement that he b Bomsed punuLl to the pmvleem of the Contractori License how(CLupter9(mmmenMgwNh Seelon MM)of Dtvl- SWIM rgNG POOL ELECTRICOa sbn3ofthe Bunn.and PmfenbreCode)orthat he be¢mpt themmmend ALDA'Dthe Wale for the alleged esemptlon. Any vlobtbn of Section 7MIS by any eppllont fora permit subjeaa the applicant to a ciil peralty u(nor more than OUTIE BWTICF�S-FDCNRES ' fihundred dollars SM. NI,as owner of the property,or my employm with wage as their sole NEW RESIDENTIAL FT FLTR SQF7. STOWIS TYPECON'.:IRUCTION compensation,will do the work,and the amumue b not betended or offered for O ale(Sec.70K Buslruas and Pmfeabns Code:The Cont icme.U¢roe Law j$ dm not apply to an owner of property who builds or impmve thereon,and OCC.GROIIP RFS WITS Mn.doessuchworkh4reeBmthrough hlaownempt ym,p.Acdithatuciu Impmvemew am.intended oroffered f«tale,l(however,theb ilLding or TOTAL: Imp vem Mntb Wwahinomyearofcompldtb theownerbuMerwBUave try�rdenof pmW"that he,did not build or improve for perpoaeof•ale.). QTy, PLUMBINGPERMIT FEE LJ Las ou`Ter of the property,am eacleaNsy contracting with Ikxnsed FLOOD ZONE APN mntnct«s to constructthe (See Business;Buslnand Professions Code: PERMIT ISSUANCE The Contnneri License Law vet appy to an owner of property who ALTER-DRAIN kVENT-WATER MAI cur Improve theme,and who comnm fee ouch pnojnv wlth a r9alpactor()Bon rd purumt to the Conract¢'s Lice.law. BACK FLOW P1�74YT.DEVICE FEE SUMMARY LJ I am exempt under Sec r B k P C for this ream Date DRAINS.FLOOR,ROOF,AREA,CONE. SANITARY Y N_ Owner RECEP T I ( WORK MAN COMPENSATION DECLARATION Fp(.NRU PER TRAP SCHOOL.TAX Y_ N_ I F11 hereby affirm that I)uvea certificate of consent to aeB-irwrc,«• ��I «rtN¢teofWarkm'Cmnpensatlonlwnn¢«a¢rtl/lM mpythemM 6cc. GASYSTEM-1P 41 OUTLETS PARKFFE Y N Policy olk abG S F.A. � I GAS EA.SYSTEM-OVER (EA) RECmrT I �Nn nY BUILDING DIVISION FEES Certifbdmpybffled furnladtybed. GREASE/WDIISTRL WASTE INTERCEPTOR PLANCHECK FEE ed ropy b filed with the mY Iropecdon dlvlsim. CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID URA N COMPENSATION INSURANCE SEWMRSANI7.ARYSDRM EA.70OFT Date RL i t# (I'hbxtlbn need not hcompletedNbf«ora hundred doBan P (SIw)«len.) WATER I6ATER w/vENr/nFrrR ENERGY FEE Y N I certifythat b the peefamanceoftheworlk fmr hlchthio permitb hued. 1-hal]not employ an/penmu in any manner u as to become ubfcttt to the WATER SYSTEM/TItFA77NG W«ken'Comperoatbn Loveofdlifomb.Date PAID Q Z NOTICApplicaE NEWRESIDDN LPLMB. SQ.FT. Date Reoel t# _Z O NOTICETOAPPLICANT:e aherers'Co thio Cemflateof Esc of the Labor shouldbmome mh ft Ne plyk t'Compersatbn ortha peolthe Labor TOTAL: H V) Codgyou const forthwith mmpy wlN arch pmvbbro orthb permX shall be U � > deemed rewked. BUILDING •'E W O CONSTRICTION LENDING AGENCY SEISMIC FEE ll thercbyaf Itttthereba mrotmm«,l mgagerwyfortl perrosu. = TOTAL ELECTRIC FEE an¢ofthe workler which thio pemdthbued bee 30ffl,CN.C) UO ader'.N me PLUMBING FEE IL f Le aeraadd. QTY. MECHANICAL PERMIT FEE MECHANICAL FCE O W Ircniythatlhav madtkT ppllatbn and aatethatthe above informal. b correct.I agree to comply with all city and county ordbunm and elate laws FERN417 ISSUANCE FEES PAID: } N relating to building corotromon,and mevby authorbe mpresnUthra ofthla F Z city to enter upon the abovemenBonrd property fee Wpeebn purposes. ALTFRORADDTOMFLti. _ (We)agree to save,hwemnty an d keep lu mness the City of Cupertino ----Datc Receipt# ago WtBablBOce,judgment, ssrNdexpenmwhichmayinanywayamue AIR HANDLING UNIT(TO 10,"CFM) SUBTOTAL• agal d dYb •�' of the gn ofthlspcmdt a7 /J ll AIRHANDUNGUNU'(OVERMODOCFM) CONSTRUCTION TAX Signature of AppO /Contractor J fiatc–/ EXHAllST HOOD(W/DUCD CONSTRUCTION TAX PAID: TARDOUS MATERIALS DISCLOSURE Will theap ntorfuture building Occupant alone or handle hazardous HEATING UNIT(TO 100,01110 Date Recti t# material as defined by the Cupertino Municipal Code,Chapter 9.17,and the Health and Safety Code Section 25537¢)} HEATING UNIT(OVER 1011,000 BTU) TOTAL: Yn r]No Ill theappllant orfuture building occupant see equipment or devi. VENTILATION FAN SINGLE RESID) ISSUANCE DATE which emit hazardous air mnlamW nts as defined by the Bay Area Ab Quality Management Dbtrkt7 BORER-NO MP HP OR IOOXW BTU) PAID Yea n No have and the mous Haleriab requirements under Chapter 695 of BOILER-OMP(OVER 100,000 BTU) y the CalBomla]leallh k Safety Cadro 6 Cade,Sectlo75505,75533 and 25531.1 SEP 1 understand that if the Wilding does M currently have a tenant that it Is my NEW RESIDENTIAL MECFL SQFT mpondbOlty,to notify the occeparu of the requirements which must he net prior to issuance d a Certlfi¢t"Oaupancy. Owncroruthorimc agent Date ISSUED BY: y, VYY TOTAL: _�I1( OFFICE COPY