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22718 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project ldendfiotlon 7 PERMIT NO. Building Address: © S .2 7 1 8 Cf; G I .era ama: one: APPLICA MON SURKfl7rA[T5XTf!- _T?/6/7*¢ - CITY OF CUPERTINO-BUILDING DIVISION Contractors Nam: Lic.No: APPLICATION / PERMIT q asse, :-` i— BUILDINGELECTMCALPLUMBING-MECHANICAL CATEGORY C 'lyb Arehllect/Engineer. Llc.Na: �p QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Add.. PERMITISSUANCE r� ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION ]herebyion70that l Division provisal Pro Chapter9(commmc- APPEANCFSRESIDENTIAL ]08 DFSCRII'IION ingwith In force aff effect 3ofthe BuslneuandPro(caslonsCode,and my �A/� �7;42— p �Z) license is in tali(ores and effect PANES cW /`— License Class Lic.N Dale Contractor UP TO 200 ANTS ARCHITECTS DECLARATION 201.10DOANPS rc0 2 I understand my plan shall be used as public records. OVER]ODO AMPS SQ.FT.FLOOR AREA S/SQ.FT. O Licensed Professional I SIGNS ELECTRICAL Q w OWNER-BUILDER DECLARATION In Fn SPECIAL CIiCU1T/MISC Ihercby a(firmthatlam exempt form the Contractor's License Law for the F9F^ following reason.(Section 7031 S,Business and Professions Code:Any city or TEMP.METER OR POLE INS(. u� ewnty which rcqulmapermlt tomntrucc,alter,impmve,demolish,orrepcir anystructure pdorto ltalssuance,alsomquires theapplicant for such permit to POWER DEVICES N file a signed statement that he Is licensed pursuant m the provisions of the 3c; Contractori License I w(Chipter9(m.ricing with Section 7000).(Divi- SWIMMING POOL ELECTRIC VALUATION IS Offm ^ sion 3 ofthe Buideenand Pfesst.n b Code)orthat he exempt therefromand C <Sthe basis for the alleged exemption. Any violation of Section 7m I.5roomby any OUTLETSSWMCHES-FIXTURES 2� ODD applicant fora permit subjects theappllcant to a civil penalty of not room than µ five hundred della.(5500). NEW gFSiDEN'IIAL ELECTR SQ.Ff. STORIES TYPECONSTRUCTION n1,as owner of the property,or my employees with wages as their ante mmpemulion,willdo the work and lhestrucwm Is not Intended or offend for sale(Sec.7064 Business and Pmfeasiov Code The Contractors License Law $ does not apply to an owner ofproperty who Wilds or Improves thereon,and C RES.UNITS who docssuchwork him e8orthrmgh hlsoweemployees,provided that such improvements are not Intended proffered for sale.If,however,the building or TOTAL: Improvement]sold within oneyearofcompleiomtheowner-bulkierwill have t eno'pmv'ng lhathe did not hued or Improve for purpou.(tile.). QTY. PLUMBING PERMIT FEE 7DNE APN L s owner o!the property,am exclusively contraciing with]&erased PERMIT ISSUANCE mt .tucontro the projpR(&c.7066,Business and Prolesslom Code: Cpnt..Or.License Law don not apply to an owner of property who - Wilds or improves thereon, and who contracts fns such piojects with a ALTER-DRAIN&VENT-WATER(EA) Cq➢1(adarts)licensed pursuant to the Contraciors License Law. FEE SUMMARY IJ 1 am exempt under S . B&P C for this reamn BACKFLOW PROTECT.DEVICE DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N� . Owner Date re or RFCEPI KMN WONAN COMPENSATION DECLARATION RATION PER TRAP SCHOOLTAX Y N F11 hereby affirm that I have a certl8vte of consent to self-trwr RECEIPT N certificate o(Workerd Compewtion Insurance use certified copy thereof(See. GAS EA.SYSTEM-1 INCA OUTLE75 PARK FEE Y N ]Policy p GAS EA.SYSTEM-OVER d(EA) RECEIPT p Com any BUILDING DI VISION FF.ES Ecertlfled copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE 6fte* Certified copy 13 filed with the city inspection division. G CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAIDq��L� 1 v—s ' 1 COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200F1' Date Remi t# (Thlsseetlon need not be completed]the permit b for one bond"dollars ($100)or less.) WATER HEATER W/VENT/ELFCTR ENERGYFEE Y_ N— I certify that in the performance of thework forwhlch this permit Is Issued, 1 shall not employ any person in any manner ro as to become subject to the WATERSYSTEM/TREATING Workers Compensation Lam of California. Date PAID OZ Applicant NEW RESIDENTIAL PCMB. SQ.FT. Date Recei t# 'Z NOTICE TO APPLICANT:If,after making this Certelote of Exemption,you Oshould become subject to the Workers'Compensation provision of the Labor _ TO L: CC fp Code,you most forthwith comply with such provision orthis permit shall he QU deemed revoked. /y W — CONSTRUCTION LENDING AGENCY S I FEE CL C Ihereby affirmthauconstruction hem is a cotction lending agency for the perform- ELE RIC Z ance of the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: _ U O 1<Mera Name PLUMB] H Lender9Add. QTY. MECHANICAL PERMIT FEE MECH 1 L FEC• Nff LL O l eertitythat l have read thisappllrationand Yatethat theaWve information FE S O 1 Ecorrect.Izgm to comply with all city and county ordinances and Yate laws PERMIT ISSUANCE relating to building construction,and hereby authmiam repersamotivn pf this U) city to enter upon the above-mentioned property for Inspection purposes. ALTFRORADDTOMECH. Z (We)agree to uve,Indemnify an d keep harmless,the City of Cupertino Date CCe1P1# V agaimtllabilltLL,pdgmnts,c sandexpevnwhich maytnanywayaccrue AIRHANDENGUNIT(TO10,000CFM) S TOTAL: agalntsal itymm equen oflh ant mg 'rtr(apernot. II� ' AIR HANDLING IIMT(OVER 10,000CFM) CONSTRUCf10 TAX Siattire pecan/Contractor FH'1 D re II I— EXHAUST HOOD(W/DUCT) CONSTRUCT] TAX PAID: HAZARDOUS MATERIALS DIS OSURE Will the applIcanl or future building occupant store or handle hanrdous HEATING UNIT(TO 100,"BTU) Date Recej t# material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code Section 25532(.)7 HEATING UNIT(OVER I0(J000 BTU) 711 aL; Yea M No Will the applicant or future building occupant use equipmant or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE which emit haurdoos air contaminants as defined by the Bay Area Air • Quality Management Dierin7 BOILER-COMP QHPOR 100,000 BTU) p 8 Ym PY No have read the haza ousmaterlalsmquimm ntsunderChapter6.95 of BOILER.COMP(OVEt 100,000 BTU) the Callfomia Health&Safety Code,Section 25505,2.55533 and 25536.1 e' = ,t �Nteayy� understand that if the building does not currently have a tenant,that it E my NEW RESIDENTIAL ENTIAL MECH. SQ.Ff. 140 (� responsibility to notify the occupant of the requirements which most be et N prior to issuance of a Certificate of Occupancy. CI .K 1tUYGHIINU QD Owner or aulhorlmd agent Date TOTAL ISSUED BY: _ OFFICE COPY