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21844 (2) APPLICANT TO FILL IN]NFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY Building Project Identification PERMIT NO. BuIldleg Addec..: - - 2 1 8 4 4 e4b - r ame' - - one: - , . 4✓ 1/116-)772 CITY OF CUPERTINO-BUILDINGDIVISION -I--LS-`( � c°"v ttnrswe: -Lic.No: APPLICATION / PERMIT ' Zf 3 Llc No: Archlteci/Englnser. BUILDINGELECTRICALPLUMBINChMFCHANICAL• CATEGORY Co � � ) QTY " ' �� ELECTRIC PERMTTI '�,��5 t'i}FLCI+=t •'�� '+''BUILDING PERMITjINPO-( . . Address: - PLUMB Mf�" PFRhETISSUANCE .❑ ❑ © ❑ LICENSED CONTRACTOR'S DECLARATION - Ihereby ion7 )ofDat ivsionsed 3 oftheunder Provisions of cesonsr9de,and c - AITLIANCESRESIDGMTAL - JOB DESCRIPTION Ingwlth Section f...fDldied. niche Bus]nessand ProteeslonsCode,and my - •^ �� P license le In full force and effect. PANELS License Cie. LIc N ' Date Carona., ARCHITECTS DECLARATION 201-1000 AMPS 0 ZO. I understand my plana shag be used ss public records OVER 1000 AMPS SQ,1T.FLOOR AREA $/SQ.IT. k Licensed Professional SIGNS ELECTRICAL << OWNER-BUILDER DECLARATION SPECL1LCUtCU1T/M15C I hereby affirm that am exempt from the Contractor'.License Law for the - p following reason.(Section 7071.5,Business and Professbns Code:An cityor FF'q county which requires a permit to coratmd,alteq improve,demolish,or reair TEMP.METER OR POLE!NST. �� ❑ any stmmm prior to its issuance,.Iso requires the a pplicant for such permit to POWER DEVICES ' Yd (� file a signed statement that he in licensed pursuant to the provisions of the Contractors License Lew(Chapter 9(commencing with Section 7000)of DWI- SWIMMING POOL ELECTRIC SOVALUATfON S slon3ofthe Businesaand Pmfentam Code)orthathei cumpttherefmmand Sr' the basis for the alleged exemptlon. Any violation of Section 70715 by any �« appBant for a permit subjects the applicant to a civil penalty of not morethan OUILETSSWITCHPSFIXfURES- p� five hundred delta.EESM. NEW RGSIDENIIAI.ELECIR p Z ❑I,as owner of the property,or my employees with wages as their sok SQ'FT. STOIUES TYPE CONSTRUCTION compensation,wlltdothe work andthe structure isnot intended or offered for ' In(Sec.7044,Business and Professions Code:The Contractors Limme Law 3$ does not apply to an owner of property who builds or improves thereon,and •OCCGROUP "RES.UNITS who does such work himself orthmugh his own employees,provided that such Improvements are not Intended oroffered formic.If howevegthebulldingor TOTAL: Improvement lseoldwithlooneyearofcompletion,the owner-bullderwlll have tl;g,¢urd.no(pmvingmat he did net bundnrimpmve for purpose nfaak.). QTY.'• , PLUMBING PERMIT "TEE. ' FLOOD zvNE APN LI I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE contractor to construct the project(Sec.7044,Business and Professions Code: The Contractor.License Law does not apply town owner of properly who - bullds or Improves theeon, and who contracts for such p�njama-with a ALTER-DRAIN&VENT-WATER(G) ♦6D _ ' FEE SUMMARY �t ctor(.exempt under Snt to the License Law. BACK FLOW PROTECT.DEVICE OUTS I III,IT I'I ' -1_I f am exempt under Sec. E k P C(or.thle reason Owner Date anon i DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N— RECETPT N WORKMAN COMPENSATION DECLARATION meq,I'ER.I.RAP ry SCHOOL TAX Y N ❑f hereby affirm that I have a comflcate of consent to self-Insure,or a s RECENT N mrtiflmteo(Workers'Compev tlonlr mnmmrame ifiedmpyihereof(Sec. CAS PA.SYSTEM-1 WC40U1LEf5 3g00,IabCJ t PARK FEE Y N— Policy N I4/C C' 4 '-OO GAS F.A.SYSTEM-OVER 4 MA) RECEIPT N Coma G - BUILDING DI VISIONIRES Certified ropy b herebyfurnished.theM1ed. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE ❑Certified ropy V filed with the city inspection division. CERTIFICATE OF ENETIPTION FROM WORKERS' GREASE TRAP ♦CES PAID . COMPENSATION INSURANCE (Thie.ectlon need not be completed if the perMt V(or ane hundred dollarsSEWER-SANITARY-51DRM EA 2(3arr. Date Recei t# ($100)orless0 WATER HEATER W/VENT/ELECTR . ENERGY FEE Y N I certify that In the performance of the work forwhlch this permit is Issued, — I shall not employ any person In any manner w as to become subject to the WATER SYSTEM/TREATING ' Workers'Compensation Laws of California.Data PAID OZ Applicant Z O NOIICETO APPLICANT.If,after raking this Certificate.(Exemplbn,you NEW RESIDENTIAL PLMB._SQ.FT. 'Date Recei t# should bcrome.ubject to the Workan'Comperaatlon pcoWions ohhe Labor TOTAL: W~ _N Code,you at forthwith comply withsuch provisions orthis permit shall be BUI G > deemed revoked. FEE W C CONSTRUCTION LENDING AGENCY - SEISMIC FEE I hereby affirm that there is a construction lending agency for the perform- ELECTRIC FEE 7 Z ante of the work for which this permit Is issued(Sec.3097,Cle.Q TOT AL: L..E) 02 Lenaer.Name - - y .. PLUMBING FEE' — LL H Lender's Addre.. QTY. .MECHANICAL PERMIT,, FEE' t MECHANICAL FEE O W 1mdify that l have mad this application and state that the above information - current.Lgrec to comply all city county ordinances statelaws PERMIT ISSUANCE FEES PAID: } 1 relating to building mmtruction,and hereby authorlu representatives of this - I— Z city to enter upon the above-mentioned property for Inspect Ion pu rposes. ALTER OR ADD TO MUCH. (We)agree to save,Indemnify an d keep harm ess the City of Cu portion Date Receipt# LS against liabilities,judgments,costs and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: ageintsald Cl onsequence of the granting of this permit AIR HANDLING UNIT(OVER 10,000 Cr•M) CONSTRUCTIONTAX gwturc tApp ort/Cont actor Date IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or(umm building occupant stare or handle hazardous HEATING UNIT(TO 100,000 BTU) Date - Receipt"!material as defined by the Cupertino Municipal Cade,Chapter 9.12 and the Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: ❑Yea ri No Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) - ISSUANCE DATE whiche Marazzniom at,contaminants ante ae defined by the Bay Area Air which eml, Mawgnment District? BOILER-COMP DERPDR 100,000 BTU) 4 Yea N No have read the ealth& nus materials requirements 2555,2553 andChapter55 .1 of BOILER-COMP(OVER100,000 BTU) FEB the California Flealthk Safety Code,Sections 2550.5,25533 and 25534.7 ' understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FI'. _ responsibility to noli(y the occupant of the requirements which must be mot prior to issuance ofaCertlfiote ofOccupancy. Owner or aulhodud agent Date ISSUED BY:J, TOTAL: OFFICE COPY