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25054 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO I•DING- MI A• PERMIT NO. O APPLICATION/PERMIT PLUMBING-MECHANICAL. BUILDING DIVISION BUILDING PROJECY'IDENTIFICATION 54 BUILDINGAUDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE 11145 Sr 3 LOT It OWNERS N ME: PI{ NE CONTRACT S NAME: ,/LIC NO: �� /- LV -u NA] COI OLM nRCHITECI/P GINEER. C NO: ADDR SS: ,/n ❑ CON'I'ACI': PHONE: —06-4? QTY. ELECTRIC PERMIT FEB BUILDING PERMIT INFO BLDG ELECT PLUMB MHCII PERMIT ISSUANCE � ❑ "tj ❑ LICENSED CONI'RACE OR'S DECLARATION APPLIANCES-RESIDENTIAL Metz Ihereby affirm that l an licrrocdundcr provisionsof Chapter 9(cnmmencing with JOB DESCRIPTION k100 Section 2lhxq of Uivisinn3of the Business end Prolessions CsJe.aA mylicense is in PANELS ,ad full force and effect. FzU me Class Lic.N UP TO 200 AMPS ky ice ��'a` N< Dam Comma., 201-1000 AMPS I '^ ZO�! understandns ARCHITECTS DECLARATION OVER 10(d)AMPS SQ.M.ILOOR AREA $/SQ,FT. CZ-0 1 understand my plashall be ued sas public records, F F' SIGNS ELECTRICAL ZY$J Licensed Professional C eQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. KOyF I hereby affirm that I am exempt from the Contractor's License Law for the Wy following reason.(Section 2031.5,Business and Professions Code:Any city or county TEMP.MF'TER IY s .A La:o l which requires u permit u1 construct,alter,improve,demolish,or repair any snucturc ,WaM prior to iv issuance,alsorcyuires the applicant for.such Permit file a signed statement POWER DEVI O kI�MO tout he ix liccaedpursuam to the provisimeof the Contractor s License Law(Chapter �-%oEl 9(commencing with Section 7")of Division 3 ofthe Business fund Professions Code) SWIMMING PO ELs I�� VALUATION WM, or that he is exempt therefrom and the basis for the alleged exemption.Any violation.( OUTLETS-SWI'IC TURFS ' F_Z Q Semina 2031.5 6y any applicant for a pemmid subjau doe nppli<ant do a civil penalty of ¢ rpt more than five hundred dollars($5010). K I-o ❑ Lnsownerofthe norm to eeswithwa csasdhcirsolecom NEW ftEYT1AL ELECIit _SQ.FT. TYPE;CONSTRUCTION grope y yemp y g pcaation, STORIES y30O will do the work,and In,smlume is not intended proffered forsalc(See 2044,Business and Professions Code:The Contractor's License Law does not apply to an owner of pmpcny who builds or improves thereon,and who does such work himself or through his ownemployces,provided that such improvemenuare not intendedoroffcred foraale.If. OCC.GROUP RES,UNITS however,the building.,impmvemem is sold withinnneyearofcmmpletion,the owner- TOTAL builder will have the burden of proving that he did not build or improve for purpose of sale.). . ❑ I,as ownertlfmhe property.ten exclusively contracting with licensed contractors to QTYPLUMBING PERMIT PEE MOOD LONE, ppN combat,16e Project Sm.2044,Business end Professions Call The Cotracto nr's l icense lawdcesnot apply man ownendpropcny who builds orimpnwes thereon,andPERMIT ISSUANCE who contracts forsuch hojem,wil somme ctorls)licensed pursuant to the Contractors License Law. ALTER-DRAIN&VENT-WATER IEA) FEE SUMMARY ❑ 1 nm exempt under$cc. ,B&P C for leis reason BACK FLOW PROTECT.DEVICE: OUTSIDE ..S SANH'AKY Y N Owner pate DRAINS-FLOOR.ROOF,AREA,GOND. RECEIM.It WORKMAN COMPENSATION DECLARATION SCHOOL'1'AX Y__N ❑ Ihereby of firm Oleo lhave acenificme of consent o,lf-insure.ora cenificam of FlXTURES-PER TRAP RF-CEIPTN Workers Compensation Insurance cracerified copy lhucof(Sac.3800,Lab C.)which PARK FE=FEE _ rivers all employees under this permit/ GAS-EA.SYSTSiM-I INC.4 OUTLETS Policy p ES Company GAS-EA.SYSTEM-OVER 4(EA) PfANCH ❑ Cerified copy is hereby famished. ❑ CcnificJ copy is filed with the city inspection division. GRIiASE INDUSTRL WASTli 1N EERCEPfOR GRADING CERTIFICATE OF EXEMPTION FROM WORKERS' DEBASE TRAP SOILS COMPENSATION INSURANCE fnissectionnced nm hcpridend iftheperrnil isfornnehumboddi lars($IW) SEWER-SANITARY-STORM EA.300177, ENERGY or less.) I certify that in the performance of the work for which this permit is issued,l shall WATER HEATER WNBNT/f;LECI'R nm employ any pen'on in any manner so it, to become subject to the WorkersPAID O z Compenstati.nlawsof Califomla. Date WATER SYSTEMMEATING Uate Rcceiptp O PP NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL: H > bcehwithc reply the Worker's Comms or this perms shall bed Lubar Coked. must � , forthwith comply with such provisions or permit shall be deemed revoked. BUILDING ftiE y O CONSTRUCTION LENDING AGENCY SEISMIC FEE z 1 herchy affirm that them is u construction leading agency for the performance of V O the work far which this pea itis i...ed(Sm.3092,Ci,C.) TO ELECTRIC FEE Lender's Name 0 F Lender's Address QI'Y. MECHANICAL PERMIT FEE PLUMBING FEE V 1 verify that I have teed thisanpl emion fund swte that the above information is Ir" ennem. lagree it,comply with all city and county ordinances and stain lows relining to PERMIT ISSUANCE MECHANICAL FEE _ buddingeore and hereby amhodu reprcsenmtivcs of this city toenter upon the U z above-mc ncA ry for inspection laureates. M OR ADD TO MECH. CONS TRUCfION TAX ^ '1c,' c7 a c �Icx�snfficiry of Cupcninp egvnsthdIu i r Is cad d swer.c.,madsaidCil, DLING UNIT(TO 10,0WCFM)on I f the 5 -7 DLING UNIT(OVER IO.OgI CFM) rates ' r um of Applican4C.ntracmr Date ST HOOD(W/DUCH PAID HAZARDOUS MATERIALS DISCLOSURE G UNIT 100.000 BTU) Dole Receiplp Will the applicant or future building occupant store or handle harard.us material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety If UNIT(OVER IW.00(1 BTU) Code,Seaton 25532(n)'t ❑Ycs ❑No ATION FAN(SINGLE RESID) • will tra,co icamnmr,as building occupant.,Area Air Quality Managerrit ment -COMP(3HP OR 100.000 BTU) ISSUANCE DATE hairpiecDismO.s air amaminands as defined by dnc Day Area Air Quality Maagement -COMP(OVER 100,000 BTU)Disrlm) IQ❑Ycs ❑No SIDENTIAL MECH. SQ.FT. A Y1 have read the haardous materials reyulrcmems under Chapter 6.95 of the Culifonlia lit he req Safety Csde,Sh .as'IN,met 25 nt 1.is2-5534of.Cirrs carte of1J(I fl� e 1�rat if the building does not currently have a tand,that it is my msponxihility to notify thetu'/{ a1993 occupant nl the rcyuiremenu which must be mel prior to issuance of a Certificate of Occupancy. /s11 y Uf 'L . Owner or authorized agent Date TOTAL ISSUED BY: OFF