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22763 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Pro'cct IdentificationPERMIT NO. Building Address: Y �.yy ��j y 22763 r9 sled: ere: A CITY OF CUPERTIN0.6UILDING DIVISION Cm ams.: L�yp;� APPLICATION / PERMIT • [b BUILDINGELECTRICALPLUMBINGMECHAMCAL CATEGORY COKBOLN re Ahao aitert/Engineer. Lk.No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: PERMITISSUANCE ❑ 1:1 ❑ LICENSED CONTRACTOR'S DECLARATION Iharebyafform that l am licensed under provisions of Chapter 9(mmmenc APPLIANCES-RESIDENTIAL JOB DESCRIPTION ingwlth5 ion7000)°f Dlvision3otthe Busimmand PmfnMmsCode,and my license is In oyyyyppgqIf effect. PANELS License Class GV LIc.K Date Contractor ARCHITECTS D RATION 701-1000 AMPS rA] I understand my plans shall be used as public records. ,OVER 1000 AMPS SQ.FT.FDR ARpq _ $/SQ.FT. Ob Fj Licensed Professional SIGNS ELECTRICAL ' 'rev, Q OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC Ix EO. 7 I herebyallrmthat l am exempt from the Contractors License Law for the T Z1- following reason.(Section 711315,Businessand Profeeslome Code:Any city or TEMP METER OR POLE INST. / Qy c°untywhlchrNulresaper ttomrutruMs ter,lmpmve,demil h,orrepAr K Q anystmMmpdmtoib Wuance,alsorequl theappbantfmsuchperMtto POWER DOCS G.V file a signed statement that he b licensed pursuant to the provisions of the — DATE �O Contractors License Law(Chapter 9(commencing with Section 7000)ofDivi. SWIMMING POOL ELECTRIC VALUATON 0 sion3 ofthe Business and ProfessionsC°de)orthat he ti exempatherefromand 6 5 the basis for the alleged exemption. Any violation of Section IMIS by any OUTLETS-SWITCHESFTXTURES applicant for a permit subjects the applicant to a civil penalty d not more than a. five hundred dollars(.&5001. NEW RRSIDENTIAL ELECTR �.FT. STORIES TYPE CON'S RUCTION F I,as owner will ted property,or my employees with wages as thele sole s.la rompenaation,wllldothe workandthe atmcturebnm invented or offered for r�' O sale(S n-7,044,Business and Professions Cade:The Contractors License Law $ docs not apply to an owner of property who builds or Improves thereon,and �$^ who does such work hunecif orthrough his own employees,provided that such OCC.GROUP RIS.UNITS Improvements arc not intended or offered for sale.If,however the W old ing or TOTAL: Improvement issold within one yearofcompletion,the owner-builderwill have th rden of proving that he did net build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN U L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE contractors to ronstnuct the project(Sec.7044,Business and Professions Code: Tu,Contractors License law does not apply to an owner of property who ALTER-DRAIN&VENTWATER(EA) Wilda or improves thereon,and who contracts for such p - - rojects with a --" cg0_t ,dor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY I_J I am exempt under Sec. B& P C for thin mason OUTSIDE FEES DRAINS FLOOR ROOF,AREA,RIND. SANITARY Y_ N_ • Owner Orta RECEIPTN WORKMAN COMPENSATION DECLARATION pIXTQgpg PER.IAAF SCI100L TAX Y N 1 hereby a((Irm that I have a certificate of consent to self-Insure,ora RECEIVE 0 c Ifleateof Worlum"Compa tion Wu nifledropythenrot(Sec. GAS EA.SYSTEM-1 INCAOUTLEES PARK PER Y N 3 00,Lab C.)O/l .w/` 1�J� t a� J� - RECEIPT Policy N GAS F.A.SYSTEM-OVER4(EA) Com env_- _ BUILDING DIV151 ON FE ES [_j Cartifled copy 6 hereby%mished. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE enified copy is filed with the city inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCESEWER.SANITARY-STORM EA.2001717. Date Read t# (Thlseenion need not M completed if the permit E forone hundroddollars (8100)°`lea.) WATER HEATER W/VENT/FLECTR ENERGYFEE Y_ N_ I unify that In the performance of the work forwhich this permit is Issued, I shall not employ any person In any manner so as to become subject to ted WATER SYSTEM/TREATING Workers Compensation laws of California. Date PAID O Z Applicant NEW RESIDFhMAL PLMB. SQFT. Date Recei t# Z NOTICE TO APPLICANT.If,after nuking this Certificate of Exemption,you shwld bemmn..bject m the Workers'Compansation proviclons of the Labor TOTAL: NP: Code,you must forthwith comply with such provblons or this permit shall be tL i deemed revokes. BUILDING FEE W - CONSTRUCTION LENDING AGENCY SEISMIC FEE d Iherebyaflmnihat there is a constmctlon lendingagency forthe perform, TOTAL: ELECTRIC FEE M Z ance of the work for which this Perrot in basted(Sec.3(357,Civ.C.) PLUMBING FEE V O Zanders Name LL I- Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE U Icertlfythtlhzversadthisappliationandatothattheaboveinformation 00 O W Is cornet l agree to comply with ail city and county ordinances and state laws PERMITISSUANCE 1S,i^ FEES PAID: Y Il rel iflding ronsimctlon,end hereby authorize representation of this F. Z cityonthe above'meNloned property for inspection purposes. ALTER OR ADD TO MECH, Date Receipt# to saveindemedly an d keep harmless the City of Cupertino AIR HANDLING UhTT(TO 10,000 CFM),judgments,coaaand expenses which rosy many ayaccrue SUBTOTAL: t cos n f the ganting of t — AIR HANDLINGUMT(OVFR l0,000CIM) CONSTRUCTION TAX pplicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applica In orfutum building occupant store or hand le hazardous HFA TING UNIT(TO 100,000 BM •d Date Receipt# material as defined by the Cupertino Municipal Coda Chapter 9.1 Z,and the Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: I] Yes U NO Will the a pplicant or future building mm pant use equipment or devices V ENIILATION PAN(SINGLE RESID) ISSUANCE DATE which emit hazardous air contaminants as dented by the Bay Area Air 'In a In • Qua lity Ma rsgcmant Dentin? BOILER-COMP OEM OR 100,"BTU) 4 Y s I-I No have read the boas cause materials requirements under Chapter 6.95 of BOILER-COMP(OVLR 100,000 BTU) n s•/ 917J h the Gliomla Health&Safety Code,Sections 25505,75533 and 75534. I 9 c understand that if the building docs not currently have a tenant,that itis my NEW RESIDPN77AL MFCIi. SQ.Fr. mxp raibilhy to notify the occupant of the requirements which must be mat ( prior to lauance Of a Certificate of Occupancy. Ca�44 fi r11HF4'1't� JI� Owner or authorized agent Data OTA7.: ISSUED BY OFFICE COPY