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22390 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification r PERMITNO. $a Ic). a,: x eP5 CrZE� au/P ' 22390 wnenO"asll.ame: ��� .p-p�J p� one: q A � R� 2�'V'-`(7 CE�2 31 CITY OF CUPERTINO-BUILDING DIVISION Contractofe Name: c.Na. APPLICATION /PERMIT L BUILDINGS.ECTMCAL-PLUMBINGMCCHAMCAL CATEGORY T'Q9L� ect/ - Lie.Na CON(t: �' TYib '4ELECTRiC PERMIT 'tI� ([ tt1`i FEE tt 'i`" I,UIBDINGPERMIT•INFOI°J'• Addrcse: eIB�VN!-)I V/of -CI .. ,.''r W( PERh17TI55UANCE t/.e LIC ENSEDCONsed un 'BDECLA RATION APPLIANCESRFSIDENTIAL I hereby affirm that( ivlicensedundernems provisionsof Chapter9(commenn OB DFSCEIr110N Ingwlth Section 7000)of Divlmon3oHhe Bumneasa dPmfessionsCode,and my limrx is in full( and effeet. , ` PANES I cues LM.N .J TTQ, ate Contractor G ,IVI� UP TO 200 AMPS ARCHITECT'S N,-,' 201.10MAMPS , XZ ]understand myplawehallbeuxdaspubllcrerores. OVER1000AMP5 - SQ.FT.FLOOR AEA S/SQ.FT. Et (� Licensed Professional SIGNS ELECTRICAL - <<�6 OWNER-BUILDER DECLARATION SPEOIALCBRCUIT/MISC ' (hereby afflrenthat l am exempt from the Contractor's License Law for the ppfollowingreason.(Section7031S,Bualneasand Profession.Code:Anytltyor 0 - TEMP.METER OR POLE INST. F countywhic m'qulmaper tWmmtruc Ater,lmpmvgdemolbh,orrepalr �O y gY any strum cture prior to its husuance,also requithe applicant forsuch permit to POWER DEVICES Vfile a signed statement that he,is licensed pursuant to the provisions of the _ - Ow30 fii Contractor's License Law(Chapler9(rommencingwithSection 7000)ofDivi. SWIMMING(Y)OL ELECTRIC thehas t fo Bumnvsand Pmfemion. Any rlation f Secmpt therefrom and ALUATION <� the(scab for the alleged exemption. Any tto violation of Section no en ou any OUTLE7SSW(TCI IF_SFI%7l1RFS applicant for a permit Subjects the applicant to a civil penalty of no morethan five hundred dollars($500). - NEW RESIDENTIAL ELECTR IT. �1,as owner of the property,or my employees with wages ea their sole �'' ' STORIES 7YIaL CONSTRUCTION compensatlon,will dothe work,andthenmeure b not leterdedoraffered for - 5 O sole&,70K Bualnev and I-mies ims,Code:The Contesdoe.License law does net apply to an owner of property who Wilda or improves thereon,and - OCC.GROUP RFS.UNITS CC.. whodoessuchworkhimselforthmgh Msownemplayeea,provldedthatmch Improvements arenot intended proffered forsale.If,however,the building or TOTAL: ( Improvement Issold withinonerarofcompleton,theawne,bu0derwllHuvs tk0jfurdenof provmgthat hedld nes WOd orimpeave for purpoxofsals.). QTY, PLUMBING PERMIT, FEE u FLOOD TONE APN L as owner tr the property,am exclusively Business and with Professions Code: PERMIT ISSUANCE SL spa TheounColprsto mrtawnsect La doe(Sec.70,14,apply t am owne fprert Code: [Jai - Wil Contractor's License Law does nM apply ci an owner of property who ALS-DRAIN&VENT-WATER MA) Wilds or Improvse tpursua and who mntrecta for such p(ojece with a ,'FEE SUMMARY ,JNafTacto"exe pt under Smnt the Convactols License Law. BACK FLOW PROTECT.DEVICE LJ I am vamp[under Sea B &P C for this reason DRAINS-FLOOR ROOF,AREA,COND. SANITARY Y_ N. ` Owner Date RECEIPT N WORKMAN COMPENSATION DECLARATION tt Of hereby affirm that I have a certificatensure at consent to eetf-I ,orFIX.Il1RES PER TRAP a Cr SCITOOL TA% Y_ N_RECEIPT N ' ttrtificate o(Workers'Compema[lon lruurance ora cenl(led mpythereof(Sec. �� I'ollryN .Z GAS G.SYSTEM-t INCA OUTLETS LETS PARKFEE-, Y_ N38M labCJ CASEA.SYSTFM-OVER4(FA) RECERTM Comy 1"4 BUILDING DIVISION FEES ertiftedop arcyIs ed, GREASE/INDUSTRLWASTE INTERCEPTOR PLANCHECKFEE Y� stied copy b(lied withth the city inspection division. - CERTIFICATF.OPCYEMPFION FROM WORKERS' GREASE TRAP PAID [y COMPENSATIONINSURANCE SEWERSANITARY-STORM FA.200FT: Date Recei IN �Is I� (Thlasecte n need not be completed If the peremit b forma hundred dollars ($100)orless.) WATER I TEATER W/VENT/ELECTR - ENERGYFEE Y N I mrtl(ythat 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 Wmkers'Compensatem Lawaof California.Date PAID Z ZNOTicant ICETO APPLICANT:It,after ma king this Certificate of Exemption,you NEW RESIDENTIAL PLMB._SQ,Ff. Date Recei t# FO' should become subject to the Workers'Compensation provisions of the Labor TOTAL: � U) Code,you=at forthwith comply with such provision orthes permit shall be BUILDING ••E 1 j deemed revoked. W F3 CONSTRUCTION LENDING AGENCY, .• SEISMIC FEE .G c CL Z Ihereby affirm that there b a construction lending agency for the perform, TOTAL: _� E'L'ECTRIC FEE a^ - 7 ance of the work for which this permit b ixued(Sec.3097,Civ.C.) U O Icndeea Name PLUMBING FEE H Lendm's Add QTY. 'MECHANICAL PERMIT FEE. LL - MECHANICAL FEE O W Escortcortifed, thatlhaveready with ais llcityndcounand tyordinaethat the abovedmateEnfom aaw.tion _ S Is mann.Iugreemcomplywlth all city and musty ordinances and mate laws PERMIT ISSUANCE FEES PAID: - } relating to building commactlon,and hereby authorize representatives otthis ' f-' Z city to enter upon the abovereentlonM property for WpMion purposes. ALTFRORADDIDMECH. _ (We)agree to save,lndemnl/y an d p hamNess the City of Cu Penton Date Receipt# all tBabil s,p dgments,coma n pensee which may In any way acerae AIR HANDLING UNIT DO 10,000 CFM) SUBTOTAL: ' ag In said yIn. . uenreo 'etingmthl permit. If AIR HANDLING UNIT(OVER IB,mocFM) CONSTRUCTION TAX of ppOca /Contrctor Win ExHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALISCLOSURE W7' 1,h,eapplicant or future occupant store or hand is hazardous HEATING UNIT(TO 100,000 BTU) Date RCCeI t# tosdefined bythe Cupertino Municipal Code,Chapter 9.17,and the witSafety Code r+.-u Section 25537(x)7 - HEATING UNIT(OVER 100,000 BTU) TOTAL: ❑ Yea No Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DA'Z'E , which emit haaardous air contaml®cats as defined by the Bay Area Ali Quality Management District? BOILER-COMP DEB'OR 100,0W BTU) - Pte• Yes No have read the hazar ous nu/eriab requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU). the California Health&Safety Code,Sectors 2550.5,M533 and 75534.] understand that if the building does not currently have a/enant,that It is my NEW RESIDENTIAL MECEE • SQ.17. responsibility to notify the ocmpant of the requirements which must be met prior to Issuance of a Certificate of Occupancy. taa.{pCaperinw Owner or authodu-d-agent Date ISSUED _7Yl{N1WiS6Rs/ TOTA1, OFFICE COPY