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22697 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Poole t ldcmificalonPsi. �►�s PERMIT N0. Building Aaareaa: r � 22697_ 2,00 6{6 i wars _ on . A A A e S V CITY OF CUPERTINO-BUILDING DIVISION APPLICATION / PERMIT BUILDINGELEC7RICALPLUMBING-MECI IANICAL CATT RY COIVI ROL N Archlt / nee Llc.No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: PFRMITISSUANCE ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION L� Thereby affirm that lam licensed under provisions of Chapter (commme- APPLIANCES-RESIDENTIAL JOB DESCRIPTION mgwlth Setion7V00)of aAslon3ofthe Buslnessand Pmfe m:sCade,and my " effect// /-J PANELS ��M Lic.N QCT C/ Contractor ContraATION 701-1WOAMPS �Z shall be used as public records. OVERI000AMP5 SQ.FT.FLOOR AREA 6/SQ.FT. ��' COC U Licensed Professional SIGNSELECTRICAL Z < OWNERBUILDER DECLARATION SPECIALCURCUIT/M1SC Ihercby a(flrm that(nem exempt from the Contractor's Licence Law for the K� followingreason.(Section 70315,Business and ProfessmionsCode:Anycityor FMpMFlutORPOLE INST. county which requires a permit to construct,alter,improve,deollsh,orrepair Q��LL Qany stmcture precarious issuance,also requireathe applicant forsuch permit to POWER DEVICES E ca U Ole me a signed nalent that he is licensed pursuant to the provisions of the c fie. Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- SWPtMINC IDOL ELECTRIC 30 slon3 of the Business and ProfessionsCode)orthat hats exemptthamfromand VALUATION 6 5 the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWITCPIESITXTURFS O applicant for a permit subpoe,the applicant to a civil penalty a nroom om than five hundred dollars($500). NEW RESIDENTIAL ELECTR SQ}T. STORIES TYPE CONSTRICTION �j M I,as owner of the property,or my employees with wages as their sole C/6 compensation,wRldo the work and the structure Is not intended or offered for 5 O sale(Sec.7054,Bustress and Professions Code:The Contractors Llcame law does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RFS.UNITS whodoessuchworkhlmalf orthrough Nsownemployees,provided thatsuch Improvements are not intended oroffered forsale.If,however,thebullding or TOTAL: Improvement bsold within oneyearofcompletiogtheowner-W Bderwlll have Trets of proving that he did not build or Improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE contraton to construct the project(Sec 7044,Businessand Professions Code: The Contractor's License law does not apply to an owner of property,who Wilds or Improved thereon, and who contracts for such pRu)eats with a ALM-DRAIN&VENT-WATER TA) cq➢.t(+teals)licensed pursuant to the Conttdora Ltcense Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY LJ 1 am exempt under Sec. B& P C for this masonOUTSIDE FEES DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_ • Owner ECL RECEB'f a WORKMAN COMPkN5AT10N DECLARATION p()(.(UgES PER TRAP SCHOOL TAX Y_ N_ ❑I hereby afflrtn that I have•certificate of consent to self-Induce,ora GAS F.A.SYSTEM-1 INCA OUTLETS PARK FEE Y RECEIPT N ceniRcamof Workers Compensatloolnsunnce or a certifLd copy thereof(Secs Policy Iab�.Ia , - PolicyN �[(� RECEIPT Com P t GAS EA.SYSTEM-OVER 4(EA) BUILDING D I VISION FEES enl0ed copy is hereby furnshsd. i N n GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE CertBied copy b filed with the city inspection division. CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM FA 2mFT Date Remi t# (Thissectlon need not be completed if the permit b for one hundred dollars ($100)or lay.) WATER HEATER W/VENT/ELECTR ENERGY FEE ' Y_ N_ I mrtfiythat N the performance of the work for which Ida penult Is Issued, 1 shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TRFATING Workers'Compensation Laws of California.Date PAID OZ Applicant NEW READENT AL PLMB. QFT. Dale Reeel t# Z O NOTICETO APPLICANT:If,after makingthis Certulcateof Exeption,you F N should become subject to the Workers'Competuatio,provisiomomf the Labor TOTAL: S > Case,you aa,at forthwith comply with such provisions rthis permit stall be BUILDING FEE doomed revoked. Itl — CONSTRUCTION LENDING AGENCY SEISMIC FEE f1 I hereby affirm that there narnmtmctlon lendingagency forthe perform TOTAL: ELECTRIC FEE Z once of the workfor which this permit is Lssued(Sec.3097,Civ.C.) PLUMBING FEE (� 2 (sender's Name LL I— Lender§Address - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE OIU Icertlfythat l have read thisappBntionand statethat theabove Info motion a (s correct.I agree to comply with all city and musty ordinances and elate laws I'IXMI"T iSBDANGE / FEES PAID,. } relating to building construction,and herebyauthorlae reprexntativcsof Nis I— Z city to enter upon theaWvcmentlomd property for Wpection purposes. ALTERORADDTOMECH. —qAdDate Receipt# (We)agree to save,IndemNly an d p harmlem the City of Cupertino V agalmtllabillties,pdgme ,cortdarde sea which may In anyway accrue AIRHANDLINGUNTT(1'OI0,"CFM) `LCID SUBTOTAL: aga Wt Id as armofthe ingofthls permit. AIRHANDLINGUNTT(OVE3I0,00(i CONSTRUCTION TAX eg MAT I ate EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: ALSDISCLO UREsWOlthfappHAmAa building oompant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t# material as defined by the Cup,utmo Mu nlcipal Code,Chapter 9.1$and the -- Health and Saf ly Cade Sctlon 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: 0 Yes N No Will the applicant or future building occupant use equipment ordeviccs VENTILATION FAN(SINGLE RESID) ISSUANCE DATE which emit hanrdous air contaminants as defined by the Bay Area Air QF theuaallity Management District? BOILER-COMP OFIP OR Im,000 BTU) Yea No �0 Thave read the haeardo s PN materials requirements under Chapter 6.95 of BDILER COMP(OVER 100,000 BTU) D California Health&Safety Code,Sections 25505,75533 and 75534.1 1 understand that if the building does not currently have atenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. qct]' responsibility to notify the occupant of the requuecavrawhich most be mast prior to Issuance of a Certificate of Occupancy. t"/��[�Q7. �s�sa�Ip� � a�'�� Owner or authorlud agent Date )SS(n;p g41L'*V f:JV/' YT1l./AW TOTAL] OFFICE COPY