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25238 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OFCUPERTINO BUILDING-ELECRI AL PIiRMI'PNO. APPLICATION/PERMIT PLUMBING-MECHANICAL. 25238 -BUILDING DIVISION BUILDING PROJECT IDENTIFICATION SUBMITTAL 8 BUILDIINNNGG�ADDRESS: J SANITARY NO. APPLICATION SUBM' ITTALDA'IL ©lQ(� ,sl� ��\UNIT# LOT0 Gr�aisaicsp OWNERS NAME: PHONE: COPTR,sCTOR'SNAME: LIC NO: as ��.�to v C O NIC CONTROL# 1RC1 ECTM"GI EER: LIC NO: ADDRESS: S,LI ❑ 7�� TACE: �� PHONE: BUILDING PERMIT INFO .�S�/-/3o Y. ELECTRIC PERMIT FET.7BLDG pECT PLUMB MBCIIJL PERMIT ISSUANCE / � ❑ LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIALJON D15CI11PTION I hembytDfnn that l am licensed underprevisions ofamper9(commencing withion 700)of Divixinn 3nfthe Businessand professions Codgandmy license is in PANELSfortyenA cffcm. _ �L //''//�� nn[[��''nu Clas 'c N UP702 AMPS 201-1800 AMPS n ARCHITECTS DECLARp [ON S tbR ARCA E/SQ.FT. ZOy OVER 1000 AMPS O a, [understand my plans shall heated ar public rtcorN. Q �; SIGNS ELECTRICAL ,j,2, Licensed Professional Cd, a OWNER-BUILD ER DECLARATION SPECIAL CIRCUIT/MISC. KOwu I hereby affirm that I am exempt from the Connector's License Lew for the W 3 LL y following reason.Section 7031.5,Business and Professions Code:Any city orcounty TEMP.METER OR POLE INST. E'u' which requires a permit to consumer,alter,improve,demolish,or repair any sumnum 3 r to its issuance.ale, ircs the licenrfor such lto file a signals]statement POWER DEVICES Bonn rct to pp panni gat pj K¢O Net he is licensed pursuant m the provisions the CLew(shaper 9(commencing with Section' p7ofDivixi0n,30fre Business and Code) SWIMMING POOL ELECTRIC VAL rnarnv Way or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FI%TURCS QSection]031.5 by my applicant for a Permit subjects the applicant toecivil penalty of 5SS nut more than five hundred Dollars(ESfa). NEW RESIDENTIALELEC]t —SQ.IT. yNFa ❑ Lthe wok,stNepsinuclmisnotinandeeswifiwedfors Nelrso.c04,Business nenSTORIES TYPE CONSTRUCTION 3Po will Dothewmk,still the he Contractor's Licensed e dosnot apply to and Professions who Code:33m Conthermal,License law rices not apply m an owner of ownenywyees.pDovidedrnvesthereon,undwho dines suchworkoroffrednnialfor through his employees.prmviJCDNm such improvemems me not imm�dedoroffered Trieste.If, OCC GROUP RES.UNITS however,the Funding or improvement is soldwiNinone yearofcompletion,the owner. builder will have the burden of proving that he did not build or improve for purpose of `ale.). - QTY, PLUMBING PERMIT FEE FLOOD ZONE, APN ❑ I,as rofthepmny,amexclusivelyconmctingwiNlicensedcontraetomto weua rhe peproject(Sec.7E4L Business and Professions Code)The Comrector'e PERMIT ISSUANCE License Law does not apply man owner of progeny who builds or improves Merton,and whnwmmes forsuch projects with accovraetm(s)licensed pureuam to rhe Conrncmra Centel Law.CeenALTER-DRAIN&VENT-WATER(FA) FEE SUMMARY C] l ata exempt under Sec. ,B&P C for Nis reason BACK FLOW PROTECT.DEVICE OLITSII)E I. SANITARY Y N Owner Data EB DRAINS-FLOOR,ROOF.AREA,COND. RECPTas WORKMAN COMPENSATION DECLARATION . SCHOOLTAX Y_N ❑ Ihaehyaffrmthatlhaveacemfica Eemrsbt to self-marm.0racenifmae of RECEIPTp FIXTURES-PER TRAP 0zken'COmpensmi0n lnsuranc cmiRed mpY thercof(Se,"B, Lab C.)which PARK FEE Y N coventimlemplo cexult _I rsa L GAS-EA.SYSTEM-1 INC. 0I1TLP.TS RECEIPT# '01icy#_ ��`el0 `3/Q BUILDING DIVISION FE S C^"T'"y '4 L GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE ❑ C eJ copy is hereby furnished. Lau 1.no crtifcd copy is filed with the city inspection division. GREASEANDUSTR,WASTE INTERCEPTOR GRADING LTTE CE 1'IFICAS'C OP EXEMPTION FROM WORKERS' CREASE TRAP SOILS ELC COMPENSATION INSURANCE. (Thismaimnneed nut be completed ifthe pennant is formal hundool dollars SIM) SEWER-SANITARY-STORM EA.20017. ENERGY FEE mr len,) I cenify the,in the performance of the work for whichthis permit is issued,l shot[ WATER HEATER W/VENTIELECTR not employ any penin in any manner so n to become subject to the Workers' PAID z Compensation Lawaof California. Date WATER SYSTNVTRHATING Data Receipt# Applicant z0 NOTICE TO APPLICANT:If,after making this Certificate of Esemprion,you should NEW RESIDENTIAL PLMB.—SQ,PT. TOTAL: N became subject o the Workers Compensation Provisions ofthe labor Code,you must forthwith comply with such previsions or this Permit shell he deemed revoked. BUILDING FEE CONSTRUCTION LENDING AGENCY SEISMIC FEE I hereby affirm that here is a construction lending agency for the Performance of V O be work for which this permit is issued(Sty.3097,Civ.C.) TOTAL: ELECTRIC PER Lender's Name s O Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE 1 certify that 1 have rest[this city an county ty ordinances Net the above information is C correctlugroeecomply henhulmahmil emuntyornives of and vetelaws atrliponge PERMIT ISSUANCE MF,CI3ANICALLLE E„t"t Z idnoengdonsuudiomend f..inspection represemerives of this city to enter upon the CONSTRUCTION TAX C) above-me).....Burse,indemnify keep ALTER OR AUD TO MECII. (We)agree n,acct indemnify and keep harmless the CityofCnpenst s against liebillties,judgnunu,c0msand expenses eorlit may in any way utter nguinsuuiJ City AIR I{pNDLING UNIT(TO IO,IXNI CFM) me�ya�xncrmJ the BrominB of this permit AIR HANDLING UNIT(OVER IQOINI CPM) Signature of ApplicanUComonter Dae EXHAUST HOOD(W/DUCp PAID HAZARDOUS MATERIALS DISCLOSURC HEATING UNIT(TO 100,000 BTU) Date Receipt# Will the applicant or future building occupmu store or handle hazarJom material HCATING UNIT(OVER 100,000 BTU) TOTAL: m defined by Npe e Cupertino Municipal Code,Chapter 9.12, it the Health real Safety Cute,Semina 23532(e)P ID Yes 13 No VENTILATION FAN(SINGLE RPSID) BOILER-COMP(3HP OR 100.000 BTU) 1PISB.UAN(aE DATE Will theapplicumorfuturcbuildingmcupanmuequipmentordeviceswhich emit 1I�r MM YY U hazardous air coularemants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) Diane,? #�WW#aDiane,?, ❑Yes ❑No aee+NEW RESIDENTIAL MECH.—SQ.FT. all 22 19tlR 1 have read the huumJouv materials requirements under Chapter 6.95 of the f{ ifhe llgthasalth&Safely Callyha Bate tenan t, tit is and 25534. Iundenotif the COY Ur Vy1+tMIlp�-1 California HeniHe tdoes Safely Codeh Sections and 25534. 1l ly understand the ocmrpt n of it uircme I which most be met prior to issuance of a Cenificue of ,,. Odea Y ��•�/ Owner or amhmrizeJ egem Oma TOTAL: ISSUED BY: