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22178 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY Building Pr.'ea Identification PIRN9TNO. Budding Address° 1 SGL. 22178 Z�3a Z I1larrrrLvlE. e am: e o q 3227 If-I-IP1"`S ZSS- CITY OF CUPERTINO-BUILDING DIVISION ZOOq / Centr no�N.me: L�tej./(J� APPLICATION / PERMIT S- Y— a n � --§5 • ' � BUILDINGELECTRICALPLUMBINC-MECFtAMCAL CA7FC'ORY CONTROL X Architect/Engineer. Lk.Na: QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO Address: PERMITISSUANCEElIVT LICENSED CONTRACTOR'S DECLARATION - �f_ I hereby affirm that l am licensed under prwislons of Chapter9(commenc APPLIANCESRFSIDENfIAL JOB DESCRIPTION ingwith Sectton7000)of Division 3oftheBusimssand ProfesslonsCode,and my license is In full fora and effect. PAN©S y Llanuslass-L; Lk.N 30 Date 201-1000AMPS UP TO 2DOAMPS ARCHITECT'SallbeDECLARATION OVERIODOAMPS SQ.ITT.FLOOR AREA 4/SQ.FT. ^re0 2 I understandeProfen my ional slue be us d a+pub4c records. LED I M �2fv] OC SIGNS ELECTRICAL 1�tj Licensed Professional OWNERexNLDER DECLARATION SPECIALCEICUIT/MLSC F, �a owingraformSectio mexemptfroessand professions om P U T E R O9..Q following reason. 70)LS,Business and Professions Code:Any city TEMP.MEIFRORPOLEINST. F'W9 countywhir mquU aperMitommtmML tegimpmve,demolbh,orrepair P M5 .d anystructure prlorto its Issuance,also requlresthe applicant forsuch permit ta 6 Ei LV file a signed statement that he b licensed pursuant to the provisions of the POWER DEVICESDAM Contractor's License Law(Chapter 9(commencing with Section 70 W)of Divi- SWprfyONG POOL ELECTRIC 5 VALUATION the has O xhm3-it Busines+and Profesalam Code)orthat heh exemptlherclromand t for the alleged exemption. Any violation of Stolon 70315 by any OUTLETSSWITCIiF5HXT11RES �j Og applicant fora permit subjectsthe applicant to a civil penalty of not more than E obi five hundred dollars(SS00. NEWRESIDFNTIALF1 TR SQFT. STORIES TYPECON'SIRUCHON ? ❑I,as owner of the property,or my employees with wages as their sole compensation,will do the work and the structure b not intended or offered for ,N8 sale(Sec 7044,B..me.sod Professions Code:The Contractors Llceree Law jos$ don not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RFS.UNITS a whodonsuchworkhimseiforthrurgh hisownemployen,provided that such improvements am not Intended oroffered for sale.If,however,the building or TOTAL: Improvement issoldwithinoneyearofcompletim,lheowner-builderwill have thA*rden of proving that he fid not Wild or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD WNE APN LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE contractorn,to construct the project(Sec.7044,Business and Professions Code: The Contractor's License Law don net apply to an owner of property who ALTER-DRAIN k VENT-WATER[EA) Wilds or Improves thereon, and who contracts for such p(oject. with a eja4actor(a)licensed pursuant to the Contractor's Llmme Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY L j 1 am exempt under Sec B k P C for this reasonOUTSIDE FEES DRAINS FLOOR.ROOF,AREA,COND. SANITARY Y_ N_ • Owner Date RECEIPT X K WORMAN COMPENSATION DECLARATION FLYTUREq PER TRAP SCIBOOL TA% Y_ N_ ❑1 hereby affirm that I have•certificate of consent to.elLinare,ora RECEIPT N certiflale ofWorkeri Compensation Insurance ora unified copythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FTE Y N 3800,lab C.)��'��1,��(rrr���rrrsss EABUILDING DI PoI1ryM U cS / GAS EA.SYSTEM.OVFRA( ) INGDIVISION FEES N Com env d dcenined apy %e Eby K,mis tea. PLANCHECK FEE Cenmed copybflled with the tlty lmpectlon division. CREASE/INDUSHIL WASTEINTTiRCEI'iOR CERTIFICATE OF EX UI PTION FROM WOR KERS' GREASETRAP PAID COMPENSATION INSURANCE SEV.,ER-SANITARY-STORM EA 200FT Date ReceI t# (This section need not be completed If the permit bfor one hundred dollars ($100)orlesv.) WATER HFATLR W/VENT/ELCCTR ENERGY FEE Y_ N_ I certify that in the performance of thework forwhich this permit is Issued, I shall not employ any person in any runner m as to become subject to the WATERSYS INITREATING Workers'Comperesation Laws of California.Date PAID 0Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei [# Z O .WTICE TO APPLICANT.If,after making this Certificate of Exemption,you P: shouldbecamesubject othe Workers'Compensation pmabloro.(the Labor TOTAL: N Cade,you must fon=th comply with such provisions or this permit shall be BUILDING FE CC j deemed revoked. SEISMIC FEE W _ CONSTRUCTION LENDING AGENCY d Iherebyaffirmthatthem Is a construction lendingagenry forlhe perform- TOTAL: ELECTRIC FEE M Z arm of the work for which this permit is Issued(Sec.3097,Civ.C.) PLUMBING FEE (.) 0 T<naer.Name LL r Lender.Aadreu QTY. MECHANICAL PERMIT FEE MECHANICAL FEE U l mnlfythatl have read thisapplicatlonand state thattheabove Information 0 W correct. to comply with all city and county ordinance and slate laws PERMIT ISSUANCE .0(/ FEES PAID: S ml.tburrobu ding construction,and hereby authomm representatives ofthb (A AL'TFR OR ADDTO METH. F Z dry enter port thea Bonee property,mr wpemm�puryose.. pate Reecipt# _ e)a e o save, n fy an d keep harmless the City of Cupertino agantI 111 nsand expenses which may In anywayaccrue, AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: ag.1 t Id m of granting of this permit. CONSTRUCTION TAX n AIR HANDLING UNIT(OVER IO,ODOCFM) Sig Lure of Applicant/ ont or Date`' EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZA R DOCS MATER IALS DISCLOSURE Will the applicant or tutu m building occupant store or hand le hazardous / HEATING UMT(TO IDQ000 BTU) S)L—f 00 Date Reuel t# material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: 30.OP ❑Yes n No Will the applicant or future Wilding occupant use equipment ordevicm VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE which emit hazardous air contaminants as defined by the Bay Area Air o FA pD ' Quality Management District? BOILER-COMP OFE'Oft 100,Of1D B'CU),3 1. 190 r!�! Yes No have readthehaza cam materials requirement under Chapter 6.95 of BOILER COMP(OVER 100,000 BTU) the California Health k Safety Cade,Semiow 25505,25533 and 25534. I understand that if the Wilding does not currently have a tenant,that It is my NEW RESIDENTIAL MECJL S'Q.FT f� responsibility to notify the occupant of the requirements which must W met prior to Issuance of a Certificate of Om pa ney. Ownermauthmizeciagent Date ISSUED BY: Js `s Pp.1 L/cAL'r l3JTAL: d, Q� OFFICE COPY