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22166 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PERMIT NO. BuildingAddres6?0,3z�z 22166 C omens •�' one: A CITY OF CUPERTINO-BUILDING DIVISION cocain mora Name: .- ZlLie.No: APPLICATION /PERMIT I-/ j--r � BUILDINGELECTRICALnUMBING-MECHANICAL CATEGORY CONTROL# Architect/Engl Llc.No: ' QTy ELECTRIC PERMIT FEE BUILDING PERMIT INFO Add. PERMITISSUANCE ❑ ❑ O LICENSED CONTRACTOR'S DECLARATION I herebySectio70 that)of am Bcusedhe under BuArovislonsolmionsCodear uc APPOANCESRESIDENISAL ]OB DGSCRB'FION Ingwlt I Yell 7000)el d effoon3o(the Budnessand Pro/esslonaCode,and • I Is In full fa pnd effort. 3 PANELS License Cla ���rJ(�U�Llc.pDate—(,- _iV CoMon ZY UP TO 2DOAHM ARCHITECTS DECLARA 201-1000 AMPS qMO 2 I understand my plaru shall be used as public mounds. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT. O Fi EJ�j Licensed Professloral SIGNSELECIWCAL <<�¢' OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC F. ! Ihereby affirm that l am exempt from the Contractor's License Law for the F 9 F p following reason.(Se ion,7m1S,Be.[..and Professions Code:My city or TEMP MFr R OR POLE INSE t� c ntywhichmquresaper ttomower,alteplmpmve,d,.Iah,orrcpair yy,Saa anystm=mprlortolts Ns ance,a6omquimstheapplicantforsuchpermluo POWER DEVICES C©s file a signed statement that he is licensed pursuant to the provision of the Cmdmet '.License Lew(Qu er9(mseencin with Section 7000)ofDivi-3�G gun3ofthe Buslnessand Pefessaimucede)arthat he is exempt thsmf.mand SWBdMING POOL ELECTRIC VALUATION Fthe basis for the alleged exemption. Any violation of Section 7(015 by any OUT LETSSWITCHFSFIXTURFS O appb..t fora permitsubjects the applicant to a civil penalty of net more than (y five hundred delta.($500). NEW RESIDENTIAL ELECT( FT. O?< c❑1,as owner of the property,or my employees with wages as their sole �' ORI TYPE CONSTRUCTION' compensation will dothe work and thestmcture isnm Intended or offered for G+ 9 O vie(Sec.7094,Business and PectessiorsCode:The Contrctoe.License Law $� does not apply to an owner of property who Wilds or improves thereon,and OCC.GRO(1P RES.UNRS who does such work himself or through his own employees,provided that such improvements arc not Intended muttered forsale.If,howevep thebuilding on TOTAL: improvement lasold within.. rarofcomple0ogtheowner-WBderwill have th�u rden of proving that he did not build or improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN I_I I,as owner of the property,am exclusively contracting with licensed PEgMITISSUANCE contractors to construct the project(Sec 7044,Businessand Professions Code: The Contractor's License Law don not apply to an owner of property who ALTER-DRAIN&VEM-WATER(EA) Wilds or improves thereoA, and who contracts for such ptojects with a FEE SUMMARY <gtil[actoKil licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE LJ I am exempt under Sec B A P C for this reason OUTSIDE FEES DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N /y Owner Date RECEIPT'# WORKMAN COMPENSATION DECLARATION FDHI)RFS PER TRAP SCHOOL TAX Y_ N_ ❑I hereby affirm that I have a l..ca c of consent d spythsure,ora RECEB'f# certl0cae o(Worken Compersatlonlreurancemacertl0ed spy themef(Sec. GAS EA.SY9HM-1 INCA OUTLETS PARK FEE Y_ N_ 3800, # CJ ; Policyp 71 DING DIVISION Com any ( �/' �L L���4]�LF, GAS FA'SYSfG4-OVER4(FA) BUILDING DI VISION FEES We Ruled copy v hereby turnisFed. PLANCHECK FEE ertNed copy is filed with the city Wpection division. GREASEANDUSTRL WASTE INTERCEPTOR CERTIFICATE OF OfEM PION FROM WOR KERS' GREASETRAP PAID COMPENSATION INSURANCE SEWER.SANITARY-STORM EA.200FT. Date ReceI t# (Thisscalon need not M completed Rthe permit Is force,hundred dollars (s100)ml..) WATER HEATER W/VENT/ELECT( ENERGY FEE Y_ N_ I certifythat 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 the WATER SYSTEM/TREATING Workers Compensation Laws of California.Date PAID O Z Applicant NEW RESIDENTIAL PLMB. gQjT. Date Recel t# Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the WorkerCompensation provisions of the Labor TOTAL: F N Code,you most forthwith comply with such provisions or this permit shall bs BUILDING FEE � j deemed revoked. li W — CONSTRUCTION LENDING AGENCY SEISMIC FEE a G Ihercby affirenthxt there Is a construction lendingagenry,forthe perform TOTAL: ELECTRIC FEE M Z aem.fthc workforwhlch this permit Is Wood(Sec.3097,CIv.C.) OO Lcoders Name PLUMBING FEE _ LL F tensor's Add.. QTY. MECHANICAL PERMIT FEE y� MECHANICAL FEE U ( rtify that l have reacithisapplicationand samthattheabove information S.(/ FEES PAID: ce O W IS correct.]ugree to complywith all city and county ordinances and slate laws ['FRMH155UANCE IL relating to building construction,and hereby authorize representatives of this H Z cityworteruponth,above Honed property for irapection purposes. ALTPRORADDTOMECH. Date Receipt# (We)agree to ndemWty and keep harmless the City of Cu porno V against llablll pdgmeyysa�roats and expenpas which may In anywayaaxue AIR HANDLING UNIT([010,000 CFM) SUBTOTAL: against e. Q JneonSryuence of the P(eggft permit. AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX Signatumof Applian rector Da IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID: DOUS MATERIALS DISCLOSURE Will theapp for fu mbuilding oaap.et storeor handle haaardous HEATING UNIT 070 10,000 B1" x�� Date ReceI t# material as def sed by the Cupertino Municipal Code,Chapter 9.12,and the - Iiealth and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: qYes �j No ill the applicant orfmme building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE which emit ha>edous eircontsminants as defined by the Bay Area Air Quality Management District? BOILER-COMP QHP OR 100,000 BTU) QYn ��I have read the hazy RoNo us materiels requimmentsunder Chapter 6.95ef BORER-COMP(OVER 100,000 BTU) s9 the California l iealth A Safety Code,Sections 25505,25533and 25534. I ` S understands building does not corrently have a tenant,that it b my NEW RESIDENTIAL MECH. SQ.FT. �porsib t10 opnfytM1com `nft�,o/(the requircmenlswhich rw.s/t be meet prior tq Y'" l-".T pang'. Owneroeau udagent ll••✓✓� - TOTAL: ISSUED BY: •'lYa aW OFFICE COPY