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22440 (2) APPLICANTTO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINTtPEN ONLY " r Building Project Identification - PERMITNO. A Building Add - /Q. . . 224 T O wnere ante: I}�E PJLlgcl�t�-o��1 97 ©SC� CITY OF CUPERTINaBUILDINGDIVISION , / ?MMZC tat°;•Name' /'� INC. _�a LIc.No APPLICATION / PERMIT _ � 1 Y lONST• IN506100 BUfLDINGELFCTRICALPLUMBINGMECliANICAI. CATEGORY CONTROL Architect/Englnee Lie NoP QTY ?�ELECTRICPERMIT.;�V'C , ,FEE ' BUILDING PERMIT INFO �,. Address: PERMITISSUANCE 12, 11) XJI !❑ LICENSED CONTRACTOR'S DECLARATION I herebyafflrm that l am licensed under provisions of Chapter 9(commere APPLIANCES.RESIDENTIAL JOB DESCRIPTION Ingwlth Sacp..7000)ofD1vWop3 ofthe Buslne.sand PreneleasCode,andm - license lelnfull f..aandeffact. - PANELS n ' Div ilia. Lon Dari 100 ( �O {/� ] �� Date �1- on or l D� ��/\\\ ate ARCH ITECI' CUBA ON 201-IODO MOPS �N ZO I patients nd my pians shall beu aspubllcrerords. OVER]WO AMPS LSQ.�H�AR�� $ /5Q.Fr . r1 d� Licensed Professional SIGNS ELECTRICAL IVB << OWNER-BUILDER DECLARATION _ 'MIp UTE R SPECIALCO2CNT/MISC Y r"' Thereby af(Imnthatlam exemptfromthe Contrator'e License Law for the 0 O^E followin reason.(Section 7llHS,Business and Profession,Code:An t or OZ R o city TFMP.MEfQtORI'OLE INS!. � countywhlch mquireaa pemNtto ronetmt,alteq improve,demalbh,orrepalr gP any,tmcture prlorto its Usuance,also requires theappBeant for such permit to R o. file a signed statement that M is licensed pursuant to the provisions of the POWER DEVICES J 3u, COntrat.re Llcemclaw(Chapter9(mmmencingwithSeion7000)ofDlvi- SWIMMING POOL ELECTRIC •ton3ofthe Buanes.and ProfemlomC°de)orthatheUexemptthemfmmand VALUATIONee < the basis"for the alleged exemption. Any violation of Secllon 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not mare thaif OUTLEISSWITCHIESFIXTURES 6 Q five hundred owner of a he p. NEW RESIDENTIAL ELECTR SQ.FT. STOP PS - TYPE CONSTRUCTION ❑I,as owner of the property,or he employees with wages r thele d.ie < sampensation,(Sec.7",Busiothe ness and rk Pcondthearudure Is he ot C.. artoeended proffered for - ❑ Mie(Sec.apply to aineaa and I property Code:The or imput°fs Liceme Taw does not applytomowno,Mpropertywhoebuilds mporimprovededthryand e-s^ whodceaeuch workhimseUorthrwgh hi,ownemplgees,provldedthatsuch OCG GROUT' RIS.UNITS improvements are not intended proffered for sale.If,however,thebuilding or r - TOTAL: 32.U improvement bsold within oneyearofcompleWo the°wner-bullderwdl have tl),jurdenof proving that he did not build or improve for purpose of sale.).- QTY.I ..PLUMBING PERMIT ' FEE+ ' I7AOp ZONE ApN u L as owner of the Property,am exclusively contracting with licensed pp(Mff ISSUANCE � 0 contractors to construct the prejet(Sec.7044,Business and Professions Code: ( - The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT'-WATER(FA) builds or Improves thereon,and who contracts for such ptojects•with a - - �' 1 - ,FEE SUMMARY + roy(IatoKa)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE `,i LI I am exempt under Sec. B &P C for this reason DRAINS FLOOR ROOF,AREA,COND. ' SANITARY Y N'" • OUTSI DE FEES Owner Date E_],here WORKMAN COMPENSATION DECLRFC=N ARATION FO(�g PER TRAP SCHOOLTAX Y_ N_ by affirm I have a that have a certificate of convent tosel4lnare,ora �' O RECFRvf N certillcate of WOrkers'Comperuaupn lruurance ora remitted copythereof(See. CAS EA.SYS'IG1-I INCA OUTLETS PARKFEE Y N 3800lab C, .) P.11cy1 th71G61� —`�1 RECEIPT a Com ny - - - GAS.EA.SYSTEM-OOVER-- BUILDING DI VISION PIi ES ❑Certified copy is heed with the GREASE/INDUSfRL WASTE INTERCEP'roR PLANCFIECK FEE ❑Certified copy V flied with the city Ivpect[on d(vi elon. CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASETRAP PAID ' COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200IT. - Date ReceI t# (fNs section need not be complied if the permit b!prone hundred dollars (81(0)orless.) WATERHEATERW/VENT/ELECTR .ENERGY FEE Y N . I certitythat in the performance of the work(orwhlch this permit is baited, — I shall net employ any person In any romper so a to become subject to the WATER SYSTEM/TREATING Workers Compensation taw.of California.Dae PAID 0Z Applicant NEW RESIDENTIAL PLMB._SQ.FT. Date Recei t# Z 0 NOTICETO APPLICANT;If,ofter makl.g this Certificate of Exemption,you should been.subject to the W°rkees Compemation provlalmu of the Labor TOTAL:' U) Code,yuu at forthwith complywlthauchprovlal...,tAb pemeigasllbe BUILDING 0� deemed revoked. II.I CCONSTRUCTION LENDING AGENCY SEISMIC FEE r a Iherebyaffirmthat there is.construction lending agency for the perform. ELECTRIC FEE Z anccoftheworkforwhrchthispermitisissued(Sec.3097,CIv.C.) TOTAL: 1 f)0 2.0 0 LL O Lendars Name PLUMBING FEE I QD lyF wer.AddmM jn. .,' MECHANICAL PE2MIT FEE MECIiANICAL FEE ' O O. Icect.It rectos ead comply with allcitl.n andante ordinhat ances sa dMatInfore tion laws S recorms.building complywlth alldcity andhereby roun.rbaerancest.tweselawn PERMIT ISNANCE FEES PAID: r relating tobullding construction,and hereby authorlu rcpressmafvo a(thb (_ Z city toe upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.tMKWN o save,Indemnt an d keep harmless the City Of Cupertino ,Date Recei t# V ,gal tllablllt s,jud price a sad ex penxswMch may in ny wq.conce AIR IIANDLINC UMT RO 10,000 CFM) SUBTOTAL: . ,gal tMidC ins saquen the at o(thispenn : -s �9 7 /j- q AIR HANDLING UNIT IO,000CFM) CONSTRUCTION TAX / Slgnatu Applicant/C tr for ate EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HA2A OUSM IALSOISCLOS RE" _ Wi to applicant or uture building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU). Date RCCe1Ft# mater) ' d-Mnod by the Cu pectin.Munlepa l Code,Chapter 9.7$and the r Health and Safety CoderI2�-(S�Ietion2S532(a)? HEATING UNIT(OVER 700,000 BTU) TOTAL: p ❑Yea of( No Will the applicant uturs building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) FSAME DATE which emit hazardous air contaminant•as defined by the Bay Area Air Quality Management District? BOILER-OOMPOHP OR 100,000 BTU) . 4Yes ®No havemad the haza"do..inter.1,requlmmenlsunder Chapter 6.95of BOILER-COMP(OVER 1 Bum BTU) �ITD. L6'9K1�� the California Health&Safety Code,Section 25505,25533 and 25534.I undemtandthatifthebulldingd.,a Mcurrcntlyhaveaterartthatltlseny NEWRMDFNTIALMECH. SQ.FT. nsporalb" purify the occ'up t of the requirements which must be met prior o spare is ificate cm as • t 7/J QL Owners=zed agcn Da `1I � - TOTAL: - ISSUED BY.�1 OFFICE COPY