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22667 APPLICANTTO'FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Protect Identification PI7RkET NO. BndamgAaarem:�� ,lq l v e n 4 2 6 6 7 .• Ownse., ' ` S�1—t �� /�.7 f--''� 1 N� CITY OF CUPERTINO-BUILDING DIVISION �y Gentracun''Nan1e` Ge.No: APPLICATION / PERMIT grchlted/Engineer. Lk.No: BLRLDING-ELECIRICAL-PLUMBING-MECHANICAL CATEGORY . CONTROL Y QTY ELECTRIC PERMIT FEE ==t BUILDING PERMIT INFO Address PFRhETISSUANCE El ❑ F1LICENSED CONTRACTORS DECLARATION I hereby affire,that l am licensed under P.WA,a.fChat.r9(comovere. APPLIANCES-RESIDENTIAL JOB DESCRIPTIONingwithS&Won700D)of Divlkon3o(the Businemand PmfeskonsCodgand my Imnse isIn full force and effect. PANELS License Clam Date Comrontractor— IM IQ 2DO AMPS �f�(� ARCHITECT'S DECLARATION 201-I0DOAMPS a0 ZO 1 understand my plans shall be used as public records. OVER 1000 AMPS i9Q.Ij.FL 6�Lu Licensed Professional SIGNSELILCUIT/ T E �n fel OWNER-BUILDER DECLARATION is Si+p-CIALCIRCUIT/MISC Y Thereby&farm A.(Seten 7031 ,B fromosthesa Contractors License law fort he U lo0ewlag re coq(Seniors 7 W Business c and Isro(emione Code:h o city it /'A TEMP.METER OR POLE[NST. KE muntywhkh requlroapermRtommtmMeller,bnprove,demolish,orrepalr q' a anystmdure prlorlo ire Lewance,also requlreslhe appBant(a such pertntt to POWER DEVICES �sas�a�fs��iYR P5 U ilk a signed statement that he b licensed pursuant to the provisions of the Q6 O u, Contractors License Law(Chapter 9(mmmennng with Section 7000).f Divi- �0� sion3 ofthe Business and Pro(emio.Code)orthet he is exempt thenefromand SWIMhING POOL ELECTRIC VALUATION 0' the basis for the alleged exemption. Any violation of Section 70315 by any G applicant for a permit subjects the applicant to a civil penalty a not more than OIITLEISSWITC}iFSEXTIlRES five hundred dollars(5500). 7 6 ❑4 as owner of the pmperty,or my employees with wages as their sok NEW ftE4DEN11AL ELECTR—SQ-ET. STORIES TYPE CONSTRUCTION mmpe wfio.,wllldothe work,andthe stmmm Luna intended or offered for O sale(Sec 7094,Business and Pr-r—kou Code:The Contractors License Law �$ does nes apply to an owner of property who builds or improves thereon,and who doessuch work himsefforlhrough his own employees,provided that such OCC.GROIIP RES AMTS impmvenxmts are not intended oro(fered for sale.If,however,the building or TOTAL: improvement is sold within oneyearofcompletion,the ownerbuaderwill have tllL�urden of proving that he did nes build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE Ff.00 wNNE APN j_j L as owner of the property,am exclusively contracting with licensed pp(MR ISSUANCE mntracton,to mmtmd the project(See.7064,BusaA m and Pro(emiom Code: a 'Die Contmetor's License Law don nes apply to an owner a Property who A r.URAW 4 VENT'-WATER(FA) builds or Improves thereon,and who..tram for such prices with a coatpdor(s)licensed pursuant to the Contnnor'e Limrue Law. FEE SUMMARY I_f I am exempt under Sec B 4 P C for this reason BACK FLOW PROTECT.DEVICE DRAINS FLOG ROOA,A SANITARY Y N Owner Date R HEA,GDND. RECEIPT Y WORIOdAN COMPENSATION DECLARATION FI('IURES PER TRAPSCIdOOL TAX Y N [:]I hereby affirm that I have a certificate of consent to self-Insure,or RECEIPT Y certificate o(Workers'Compensudmlruu men ora mrtifled ropy thereof(See GAS EA.SYSTEM-1 INCA OUTLETS 3800,Tab CJ PARK FEE Y_ N_ Policy Y GAS EA.SYSTEM-0VER 4(EAJ RECEIPT Y Cam any i BUILDING DIVISION FEES [Certified copy b hereby th the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE ❑Certi/ied copy V filed with the my Inspection division. CERTIFICATE OF UMPFION FROM WORKERS' GREASE TRAP PAID CM lxPcm COMPENSATION INSURANCE SEWELSANITARYSTORM EA 200FT Date Receit# RsM hlalon need nes becampined[the permit Isfa one hundred dollen p (5100)or tem.) I WATER HEAT'Et W/VENT/ELECTR ENERGYFEE Y N I not that U the performanceny manner for which toe permit ie Issued, — I ahrR nes employ any person In any manner an m to become subkd to the WATER SYSTEM/,TREAD[G Workers Compensation laws of Callfomla.Dale PAID O Z Applicant Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB.__SQ.FT. Date Recei t# Fshould become subject to the Workers'Compensation provision of the Labor ��- ` �� TOTAL: N Code,you nest forthwith comply wdthsuch provisinruorthb perrushallbe V`v W > deemed rooked. -BUILDING SEISMIC FEE CONSTRUCTION LENDING AGENCY CL Thereby affirm that them ha.mtmmon lending agency,CA.rtheperform- � Q once onne work rer wnkn this emelt is L+mred TOTAL: LECI'RIC FEE V p (see JD97,cw.c.) Ox PLUMBING FEE Icnders Name U. f Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE O W l certitythatl have read thbapplIcation and statethat theabove information IL bcAmd.l agree to comply with al cttyand munlyordinances and state laws PERMIT ISSUANCE FEES PAID ). N relating to building omxrudluk and hereby authorize representatives of this I— city mWER to enter upon the above-mentioned property for pecuon purpose,. ALTOR ADDTO MECH. Z V Z (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date ReceiPl# against liabWties,judgments,mks and expenses which may in anywayacerus AIR HANDLING UNIT(To I0,0D0 CFM) SUBTOTAL: w, agalrut said Ccitypconee ¢ lryena(the gra esti�R �--o(thle permlL HeV►,alTLr l AIR NDUNc UNIT(OVER lB,DoocFM) CONSTRUCTION TAX Sgnawns of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAM R DOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or hand IAI,anrdous HEATING UNIT(TO 100,000 BTU) ' Date Recei f# material as defined by the Cupertino Municipal Code,Chapter 9.1 Z and the Health and Safety Code Section 25532(a)i HEATING UNIT(OVER 100,000 BTU) TOTAL: r ❑Yn No B11the zppiionl or tum bulldingoavpantuseequipment ordevim VENTILATION FAN(SINGLE RESID) ISSUANCE DATE which emit hazardous air mnta Mnants as defined by the Bay Area Air Rft�e_� • Quality Mamgement District? BOILER-COMPpFIP OR 100,IXb BTU) f� 4 4 Yrs 11 No ��LLLI havereadthebaza frtymaterials SeoIqulrementsundernd255 6.95 of BOILER-COMP(OVER 100,000 BTU)' the CellfornU Health A Safay Code,Sedlom 25505,255J3 and 25531. I uG w s understarad that if the building does not cum tlyhaveatenantthatit Esmy NEWRESIDENTTALMECH. SQ.E-T responsibility to natty the occupant&the requirements which must be met prior to Lmuance a a Certificate of Oempancy. JQ4r M Owner or authortred agent Date ISSUED BY. \�M+'�l TOTAL: OFFICE COPY 4 f CUPERTINO SANITARY DISTRICT 'Phone: 20065 Stevens Creek Boulevard, Room 204 (408) 253-7071 Cupertino, California 95014 N2 3199 • RECEIPT OF FEES Received froni: ...... ... ............... Date fit.z.e5?1 (Address) ....... �.�.4 .......................... .. 4-1-- ................. Check (No..... 5.:7........ Cash in the amount of $1...... �/.......... Property Locatibri: L.I.D. No......... Parcel No......... Tr. No./(::�. Lot No..7 otlicl. ..................:................................................................................. ............................. Joh No. Received for ths purpose of: Amount P Trust Fund M & 0 1. Connection Permit Fee (No..................................) $. .............................. $................................... 2. Sewer Service Charges (.....................Mo. @ $ ...................... ................................ .................... .............. 3. Backilow Ptotc(iivc Device Inspection Fee . . . . . ................................ .......................... 4. Connection Fees Zone No. ............................................................ a......................1--iont Ft. @ $......................... /ft. . . . . . ................................ ................................... F "R" Line" .......................*..........*...........................*......................................... 1).................Acres at $........................../Ac. . . . . . . ................................ .................................. c...................._Add. Dwelling Units at $......................... /ea. . . ................................ .................................. 5. Lateral Sewer Permit (No. ..............................) I a. Permit Fee . . . . . . . . . . . . . ................................ .................................. 1). Construction Charge ..............................ft. @ $......................./ft. ............................... ................................... c. Cost of "Y" Connection to Sewer . . . . . . . ................................ ........................... ....... d. Other.................................................................................................... ................................ ................................... 6. Checking & Inspection Deposit . . . . . . . . ..........................I...... ................................... ........................................................................................................................ ......................... .............................................................................................. 7. Annexation a. Processing Deposit . . . . . . . . . . . ................................ ................................... ........................................................................................................................ ................................ ............................. 1). Acreage Fee.......................Acres at $......................./Ac, . . ................................ ................................... 8. , -7 r 67 ... ... .. . .. . . ... ....... 'I'OTAL $................................ 7 MARK THOMAS & CO. INC. District Engineer & Manager by ZLO� 1�--