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22206 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PERMIT NO. Bulldiny 1 4 122206 neeN Phone: A .AGC.C� CITY OF CUPERTINOLBUILDING DIVISION Centra ' ossa m. APPLICATION /PERMIT �+ BUILDING-ELECTRICALPLUMBINGMECHAMCAL- CATEGORY CONTROL N • Architect/Engineer. LIB N. 'QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address PERMITISSUANCE ❑ LICENSED CONTRACTOR'S DECLARATION I hereby affirm that l am Beensed under provisions of Chapmr9(mmmen APPLIANCES-RESIDENTIAL JOBD RIPHON ingwlth Sectian7000)of DiV,m.3ofthe Businessadi ProfesslonsCode,and my Ilrcnrebin full and d(ect. / - PANELS License Clam LILY �J Date�� ds or T BUILT be used DECLARATION OVER00 AMPS ' mOp [undemtand my pions shall be used as publlcrecotdw OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT. zLicensed Professional 9CN5 ELECTRIGL �Q OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC 71-' Ta I hereby affirm that l am exempt from the Contractor's Llrense Law for the qqqqqq following reason.(Section 7031,5,Business and Professions Code:Any Ary or Ft'cy countywhich requlresa perreft to construct,alter,Improve,dennlbh,orrepair TEMP'METER OR POLE INST. ggqIS aa anyswclure priortolts issuance,also requlresthe applicantforsuch perMtto (OWER DEVICES c.V file a signed statement that he he Bmnsed pursuant to the provisions of the 3" Contractor's License Law(Chapter9(comennecing with Section 7000)of DWI- SWIMMING POOL ELECTRIC - F, OJ sion3ofthe Business and ProfessloreCode)orthat he is emnipltheradmund VALUATION P1 ...5333 the bash far the alleged exemption. Any violation of Section 7011.5 by any OUTLETSSWITCHFSHXTl1RFS Po L DOCDCpermit applicant fora pit subjects the applicant to a civil penalty of not more than five hundred dollars($500). NEW RESIDENTIAL ELECTR �n ❑1,as owner of the property,or my employees with wages as their sole SQx7' STORIES TYPE CONSTRUCTION c mpe...if.,wllldothe work,and lhesbucture is not intended or offered for na axle(Sce.7(77,Businmsand Professions,Code:The Contractor's Licanse Law $ does not apply loan owner of property who Wildsorlmperees thereon,and OCCGGROUP RES.UNTTS who does suchwork himself or through his own employees,provided that such Improvements arc not Intended or offered for sale.If,however,thebulld Ing cur TOTAL: tis Improvement Is sold within one yea rofcompletlon,the owner,W11derwlll have tIj!Trden of proving that he did rot build or Improve for purpose of sale.). QTY, PLUMBING PERMIT ; FEE FLOOD ZONE APN L,J I,as owner of the property,am exclusively contracting with llmnmd PERMIT ISSUANCE. rordecti rs to construct the project(See.7074,Be slneas and Pudesslons Cade: The Contractors License Law does not apply to an owner d property who ALTER-DRAIN&VENT-WATER(EA) Wilds or improves thereon, and who contracts for such pWicels with a ceB([ador(a)hared pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY LJ I am exempt under See. B &P C for this mason • DRAINS FLOOR ROOF,AREA,COND. SANITARY Y— N— Owner Date RECEIPT N WORKMAN I have.COMPENSATION DECLARATION FIXTURES-PER TRAP SCHOOL TAX Y— N— I hereby affirm that I have o l rtumne of consent to py theu (ora REC=X crt Late ofWorkeri Compensatlenlnsurana oraceni(ied copythemaf(gec. GASEA.SYSI'FM-1INC.70UTLETS Oic lab CJ PARK FEE Y_ N 'ollryRFOEIITN CoGAS PA.SYSTIM-OOVER [ BUILDING DIV ISIONFEES edified copy b hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE Certified copy is filed with the city inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' CREASETRAP PAID COMPENSATION INSURANCE SEWER-SANTTARYSTORM EA 200FT. Date Recei tN Rhissedbn need not be completed l(lhe permit b fororm hundred dollars ($100)otifyth WATER HEATER W/VENT/ELEOTR ENERGYFEE Y N I cent that In tany perhe son In an the week fora towhich cone,his subject c issued, — T shall not employ any perms In any manner n u to become subject to the WATER STSIEM/TRFATING Worlicn'Compensatlon Iowa o(GII(ornla.Date PAID O Z Applicant Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you FLEW RESIDENTIAL PLMB. SQ.FT. Date RCCCI Ile Pshould become subect to the Workers'Componsatlon provisions of the Labor TOTAL: CC T Code,you must forthwith comply with such provisions or this Permit shall be > dmmed revoked. B I D Uj — CONSTRUCTION LENDING AGENCY SC•ISMIC PEE CL C IhembyafOrm that there is a construction lcndlogagenry for the perforrry TOTAL: ELECTRIC FEE Z ance of the work for which this permit b issued(Sec.3097,CIV.C.). V 4 Tender's Name PLUMBING FEE LL f- Iandce.Addrem QTY. MECHANICAL PERMIT FEE MECHANICAL FEE O W IrenlfythatlhavemadtM applimtlonandrtatethattheabovelnformation S ecorred.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID: >. W relating to building commudion,and hereby authonu representatives ofthb H z coytoenter upon the above-mentioned property for Inspection purposes. ALIERORADDTOMECH. (W e)agree to save,indemnify an d keep harmless the City of C penin Date Recelptri agaWtliabillties,judgments,copes ties which may in any w acau AIR HANDLING UNIT I0,000CFM) SUBTOTAL' again Id City Inc s ceof a anif ofthlepermll. AA1ZQ AIR HANDLING UNIT 10,000CFM) CONSTRUCTIONTAX Si reo(Appl snit o tractor ate i EXHAUST HOOD(W/DIK77 CONSTRUCTION TAX PAID: A RDOUS MATERIALS UISCLOSU ' ill the applican or future building oavpant store or handle h ardoue HEATING UMT('To 100'0008, materialasdeOned by the Cupertino Municipal Code,Chapter 9.1$and the Date Recel tlt health and SafetyCode Sedion 25532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: Yn No Will the applicant or lure building occupant use equipment or devices VENHLATON FAN(SINGLE RESID) ISSUANCE DATE which endl hazardous air dentambunln as cie0ned by the Bay Area Air Quality Management D❑istrict? BOILS&COMP OHPOR 100,000 BTU qYee N No have readthehav ous materials mqulrements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) the Glifomh Health&Sifety Code,SediOns 25505,2SS33 and 25537.1 ` understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH.— SQ.FT. LT responsibility to notify the occupant of the requlremenls which most be met prior to Issuance of a Certificate of Occupancy. Owner or authorized agent Date ISSIAI, N X TOTAL: OFFICE COPY T� 1142 Sco and Dr. � • T� C3 0 u. "O 1 jot 8�, 1 � s 6 � 47.5 44.5 CO m Zc Z '.12 FE9 o C;ig! —4 1 54' •1�ti N ..