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22758 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY BuildingProject Identification PERMIT NO. f ItulldingAddm s; 22758�r�Wrn7-�S�a nems eine: � l 11hons: CITY OF CUPERTINO-BUILDING DIVISION ^�� Q G ^ty^iaNam: Lie.No: APPLICATION /PERMIT rchited/Engineer. Lk.N. BUfLDINGELECTRICALPLUMBINC-MECHAMCAL CATEGORY CONTROL N e� QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: �� ..J• PERMITISSUANCE IrV11 LICENSED CONTRACTOR'S DECLARATION I hereby affirm that l am licensed under provisions of Chapter 9(mmmenc APPLIANCLSRESIDENTIAL JOB DFSCRIVI ION ingwfth Section7000)of Divigon3ofthe Buslncvand ProfesmonsCade,and my limners is in and effect 9 5 PANELS Date ConOAMPS tractor UP TO 2DOAM ARCH ITECPS ECLARA N µqqµ!!uot0u�O I understand my plain shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA E/SQ.FT. Licensed Professional SIGNS ELECTRICAL Q c% OWNER-BUILDER DECLARATION („ y Iherebyaffimnthetlamexempt fromthecontractor:License Lawforthe SPECIALCIRCUIT/MISC 70 o following reason.(Section 70115,Business and Professions Code:Any city or '(�(p METI]t OR POLE INSf. ut countywhich mquimsa permit reconstruct,alter,Improve,dennlish,orrepair P any structure prion,its bwancealso requireatheappllcant for such permit to OWER DEVICES 1 V file a signed statement that he b licensed pursuant to the provisions of the �3w CmondorsLicense Law(Chapter9(mmmencingwith Section 7000)ofDivi. SWIMMINGPOOLFS,ECIRIC VALUAi N sion3ofthe Buslnessand ProfmlomCWe)orthalhebmmpttherefmmand D G the Lasts for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFIXTURES D t applicant for a permit subjects the applicant to a civil penalty M room ore than c. DO flue hundred dolWs(SSW). NEW RESIDENTIAL ELECTR SQFT. STORIES TYPECONSTRUCTION '9..' n I,as owner of the pmperty,or my employees with wages as their sole �7a coropenszid..,wlll dothe work,and the structure b not intended or offered for cele(See.7044,Business and Professima Code:The Cmunictats License law 5 Q does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RFS.UNITS who doeswch work himself or through his own employm,provided that such improvements arc not Intended proffered for sale.If,however,thebuili ing or TOTAL: Improvement bsold within oneyearofcompletlon,theowner-bullderwill have tFcjmrden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN Lf L as owner of the property,am exclusively contracting with licensed PF"IT ISSUANCE contractors to comtruct the project(Sec 7044,Business and Professions Code: The Contractor's License Law does not apply to an owner of property who ALS-DRAIN&VENT-WATER IRA) Wilds or Improves thereon,and who contracts for such ptojects with a FEE SUMMARY otactor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE 1�I am exempt under Sec B &P C for this reasonOUTSIDE FEES Owner Dns S FT DRAINS- ROOF,AREA,COND. SANITARY Y_ N_ RECEIPT I WORKMAN econsentNSATION DECLARATION FIXTURES.PER TRAP SCI POOL TAX Y N F11 hereby affirm that I have avhave a certificate of consent to self-Insure,ora RECEIPT M certificate ofV✓orkers Comperaalon lmurance ora certified copytherrof(Sec. GAS E.A.SYSTEM-1 INCAOUFLETS PARK FEE Y N MOD,Lab C.) — Policy s RECEIPT N Co any GAS-EA.SYS ENt-OVER4IFA) BUILDING DIVISION FEES fCertl copy is hereby famished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANC]iECIC PEE Bled copy V(14d with the city IwpeRion division. CCRTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAIT PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date RCCCI f# (fhlssedlon need rad he completed if thepemdt ixfomom hundred dollars (flm)orless.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N— I mr ifythat In the performance of the wwk for which 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 Califomia. Date PAID Z. Applicant Date Remi t# Z Z NOTICE TO APPLICANT.II, ki ,after making this Certificate of Exemption,you NEW RESID[NDAL PCMB. SQFT. H0 should become subject to the Workers'Compensation provisions of the Labor TOTAL: cc (0 Code,you most fort hwith comply with such provisions or this permit shall be BUILDING FEE •�� deemed revoked.CONSTRUCTION LENDING AGENCY SEISMIC FEE •fro ll o Ihereby affirr^that there is a comrmfion lending agency for the perform ELECTRIC FEE 7 Z ..ce.fthaworkf.rwhkhthbperMtis swed(Sec.3097,Civ.C.I TOTAL: 00 Lcnder's Name PLUMBING FEE LLT lander'.Addoess QI'Y. MECHANICAL PERMIT FEE MECHANICAL FEE O 1 ceNfythatI have mad t his application and slate thatthe above Information O W Ls coved.I agree to comply with all city and county ord lnanm and gate laws PERMITLSSUANCE FEES PAID: Nrelating to building construction,and herebyamhorizerepresentativesofthis F Z city to enter upon the above-mentioned properyforimpection purposes. ALTER ORADDTO MECH. Date RCeeipt# (We)agree to save,Indemnity and keep harmless the City of CupeNnn V AIR HANDLING IIIJIT(TO 10,000 CFM) against t liabilities,judgirents,cogand expenses which may In anywayaccme SUBTOTAL: nret +OCn in con ribs grant otcols rmR. CONSTRUCTION TAX ��X�� AIRHAN HOOD(UNIT(OVER l0,fJ00CFM) Signature of Applicant/CSigrature of trador� IXHAUS"THOODIW/DIX:77 CONSTRUCTION TAX PAID: HA DOUS MATERIALS DISCL URE Will the applicant or future building occupant store or handlehazarciom HEATING UNIT(TO 100,ODO BTU) Date Recei t# material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Ilralthand Safety Code Section25532(a)? HEATING UNIT(OVER 100,00)BTU) TOTAL: S ❑Yo M No Will the applicant orfuturebulldingoccupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE which coat haza minus air cents oanants as defined by the Bay Area Air PAID m ' Quality Marageom Distad? BOILER-COMP QHP OR 100,000 BTU) ill 4Yrs QNo heve read the hazardous materials requirements under Chapter 6.95 of BOILERCOMP(OVER 100,000 BTU) 8 7��1 the California Health&Safety Code,Sections 75505,25533 and 75534.1 Ff 1 / a rad ersn rad that if the bu fid ug does not m mently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. responsibility to notify the occupant of the requirements which at be met asp��`a prior to Issuance of a Certlfictte of Occupancy. _�V , f<r(Ina..y Errj Owner or authorized agent Date rorncEDBY:�/4 �V4C : ISSU - OFFICE COPY A Elizabeth Elaine Lloyd 20154 Northwind Sq Cupertino, CA 95014 9-18-91 Robert Trout Sundance Skylights San Jose, CA Dear Mr Trout: This letter is to confirm that I have received verbal approval from the architectual committee of Northpoint Homeowner Association to have skylights installed at the above address. This permission was given at the July committee meeting. • Sincerely; llzet�al� 41xzc�� 4e�e— Elizabeth Elaine Lloyd • BLDG. DEINSPECT&OnPEgijNA •