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19474 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project identification - PERMIT NO. Building Address; " 2--oTTSA cur,�Rr,�o 19474 neION SU HWII77�L� A4R a-_. Phone:MRS,- 10-SETH Owl- - -. . CITY OF CUPERTIN0.BUILDING DIVISION Contractors Name: I Lic.No: . APPLICATION /PERMIT f( a 0d Co- r 'BUILDINGELECTRICAL-PLUMBING-MECHANICAL CATEGORY CONTROL Architect/Engineer. NY R Llc,Ne: ' 'QTY ELECTRIC PERMIT' FEE BUILDING PERMIT INFO Addrees: 5'Iri �AJ7ub)Z CAM PERMITISSUANCE PLUMB(� t❑ LICENSED CONTRACTOR'S DECLARATION I hereby affirm that l am licensed under provisions of Chapter9(mmmena APPLIANCES-RESIDENTIAL - JOBDESCRI770N ingwith Se on 7000)of Divlslon3 ofthe Business and ProfesalansCode,and my . license is in full fo and ailed. ♦ PANEiS ' /,t4,.rN License Cla Lic.R .�Y�a 8D 1 - •/ l��� Q� Date' Contraaor�D((,- GTe/CUP TO 2DOANIPS ARCHITECTS DECLARATION 7014000 AMPS p�p�vvQCOCIundemtandmyplamshaRbeuwdaspubhcremrds OVER1000AMPS - SQ.FT.FLOOR AREA $/SQ.FT. }i od U Licensed Professional SIGNSELFOTRICAL < ul 6 OWNER-BUILDER DECLARATION a SPECIALCIRCU[T/MISC Ze., owing cafnrmthat Iamexempt 31.5,B(romthe Contractor's License Law fort he pp following reason.(Section 78115,Business and alter,imps w, Code:Any rep it '.0Z,t.� TEMP.METER OR POLE INST. ." � - county ctur,requires pemNce,atsutmuireatheapmventfors ch,orrepalr any atmdure t.menepriorto lbhat he to licensed pursuant t the provisions such of it a POWER DEVICES file a signed statement that he h licensed pursuant it the pro 7000) of the 3µ Contractors License Law(Cha pter9(commencing with Section 7000)o(Dlvl- VALUATION In SWIMMING POOL ELECTRIC elon3o(Ihe Busineeaand ProfembruCade)orlhat hely excmptthere(romand �5epu o•] the bash for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFIXI'URFS 6e� /I,) 9 Q• aJ O appReent fora permit subjects the applicant to a civil penalty of not more than a t1 �j five hundred dollars($500). 5Q.FT. STORIES TYPE CONSTRUCTION C"C NEW RESIDENTIAL ELECTR �n ❑Las owner of the properly,or my employees with wages there sok compema 0K wllldothework nd Pre essi eatrudurehnot ontrandedctor or License d for I.. saIn(Sec.apply Bushes and f property Code:The Contractors the me Law _ docs not apply to an owner of property who builds or improves Ihereory and OCC.CROUP RES.UNITS whodoe.entsasmchor khMsendedcroffe ed owns.If,hoea,pr thebu lding r improvementsarenot Intendneyearffc=prsal thho ee buUderwdI have TOTAL: improvement hervingsold that he did otbuil plr Improve purpose of sale.). off- 7 5• IILe-purdenofpmving that he did not build or improve for purpose o(mleJ. QTY. ,PLUMBING PERMIT FEE FLOOD ZONE APN LJ L as owner of the property,am exclusively contracting with licensed PERMIT SSUANCI contrsctors to mec.natmd the project(S 7014,Business and Professions Code: The Contractors License Law does net apply to art owner of property who ALTER-DRAIN AVENT-WATER(EA) belles or improves Ibende, and who contracts for such projects with a Y FEE SUMMARY ��RRlCactor(s)licensed pursuant to the Contractor's License Law. L,J I am exempt under Sec. - B k P C for this reason BACK FLOW PROTECT.DEVICE Owner Date DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y' N RECEI7 M WORKMAN COMPENSATION DECLARATION FIXTURE&PER TRAP SCHOOLTAX Y N ❑I herebya(firm that I have a certincare of consent to self-Insure,ora - RpC=M certificate ofWorkes''Comper atlonlexurance ora certified mpythersof(Sec. GAS F.A.SYSTE24-1 INCA OUTLETS PARKFEE Y N 3800,Lab C.) - RECEIPT Policy M GAS F.A.SYSTEM-OVER 4(FAT Comany - BUILDING DIVISION�Cerlified copy h herebyth the city CREASE/INDUSCRL STF 1NTERC PLANCHECKFEE 33 ❑CedKletl ropy h Mihai with the city impaction dlWelon. / /�.�' A CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP - PAID 1-+fO � t COMPENSATION INSURANCE SEWER-SANIT Y- EA. FT Date Recei t>< (Thissedlon need notbe completed l(Ihe permit is torous re hundd dollars (BIC(Borless.) WATERHEA / ec.I:R ' ENERGY FEE Y N I certifythat in the performance of the work for which this permit la Issued, - I shall not employ any person In any manner so as to become subject to the - WorkeW Compensation laws of Callfomla.Date WA SY NO PAID Z 0 Applicant Date Remi tic NOTICE TO APPLICANT.If,after making this Certificate ofFxemptlon,you PLMB. SQ. should became subject to the Workers'Comp....it..provlslom o(the Labor v, TOTAL: N Code,you most forthwith comply with such pnwislom arthis percetshall be BUILDING FEE LU j deemed revoked. CONSTRUCTION is a ON LENDING AGENCY SEISMIC FEE -O D Z eofth work.ffl"!thatthemt hammtmctlond lending agency Civ. .) pedomF TOTAL: - ELECTRIOFEE .� � Tender the work(or which this permit hiswed(Sec.3097,Civ.C.) (.) 2 lender's Nan.' - PLUMBING FEE I4, F LendersAddresa QTY. ECHANICAL PERMIT FEE on MECHANICAL FEE OW Icect. thsal Iameto complyad happllcitynand dcuntyordinances ndgatelaws , 'L hco,mtobuilding comtmotioh andtyandcouhorladmpreseand gate laws PERMIT ISSUANCE ��� FEES PAID: �. U) relatingoenteru pont cotutructiontioned rebyrty orizerepreaenpurpon of this (— cltytaenteree to theabovemnify an d property harmless Cit purpose. ALTER OR ADDTO MECH. QaQ� Z Date Recei tN (We)agree to cave,Indemnify and keep harmless the City of yCupertino - V against liabilities,.senh,metsand expenses which may in anyway same AIR HANDLING UNIT OO l0,lXq CFM) SUBTOTAL: against sold City in consequence of the granting of this pennB' CONSTRUCTION TAX AIR HANDLING UNC!(OVER]O,lXIOC[M)' Signature of Applicant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE - Willtheapplicantmfuture building occupant store or hand le hazardous HEATING UNIT(TO 100,000 BTU) Date Recei tM material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the Healthand Safety Coder.-S�ection75537(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: (r ❑Yes u No Will the apphcantorfuture building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE - which emit hazardous are contaminants as defined by the Bay Area Air" lity Management El No BOILER{AMP OHP OR]00,0(10 BTU) Yes ❑No �1L.fix q s have read the baaaMoua materlah iequircmenls under Chapter 6.95 of BOILER-COMP(OVQt1W,000BTU) the CalBemis Health A Safety Code,Sections 25505,75533 and 75534.1 understand that lithe building does not currently have a tenant,that it is my NEWRESIDENTIALMECH. SQ.I7. respomibllity to ndify,the occupant of the requirements which moat be and - prior to issuance of a Certificate of Occupancy. Owner or authorized agent Date TOTALISSUEDBY: V CJEE n4-W"-`L` 4 : c OFFICE COPY _ — -aid