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22551 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT-PEN ONLY Building Project Identification PF.RMITNO. Building S©Q S n elates brI Ve- (/1 tel. _1,10 5o •- 22551 TY7nere ams: ne: 1,� pp gg - /y +h Lee 1' yO�-7 1 CITY OFCUPER IVC BUILDIISG I ISION ntractore Name: Lic.No: APPLICATION / PERMIT - S A31-/ BUILDING-ELECTRICA4PLUMBMG-MFLHAMCAL CATEOC Y CONTROL .Adhitect/Ingmear. - LIc Na '.QTY I 'ELECTRIC PERINI-Ft ' 1 BUILDING PERMIT INFO- Address: PERMITISSUANCE LICI:NSI:D CONTRACTOR'S DECLARATION I hereby affirm that l am licensed under provisions of Chapter9(commenc APPLIANCESRESIDENfIAL- W - JOTS DESCRIPTION ingwith Section 700(0)of Olvldon3 ofthe BminessanciPmfeddon6Code,and my license ii,Ir Zn slit affect, PANELS � — LicenacCla® c s Z Dat -�-�ont ctn /��J p/o vS�O/ n r L/ V„ -ARCHITECTS DECLA ON OVER00 AMPS - q�u0C70, l understand myplaroshallbe used as publicremrds. OVER 1000 SQ.Pp.I4.00R AREA $/SQ.FT, jx tj Licensed Professional TRIC OWNER-BUILDER,DECGRATIOiq TALC T/MISC ' ZH^ry� Ihereby affirm that l am exempt from the Contractor's License f the following reason.(Section 7031.5,Business and Professions Code:Any city T countywhich requires.permit toconstrud,alter,improve,derroliah;orrepair TAMP ETGRORPOLEINST. ' , anystructure prlortolt.Issuance,also requlrestheappacantforsuch permit to ruEy V file a signed statement that he Is licensed pursuant to the provisions of the POWER DEVICES Contractor's License Law(Chapter 9(commendng with Section 7000)of Divi- - SWIMMING POOL ELECTRIC DATE 3� { O sion3 ofthe Business and Profesel.m Cods)arthat he b exempt therefrumand VA ATI(jN the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESSFIXTURFS -(1 U U G applicant fora permit subjects thea pplinct to a civil penalty of not nere than o five hundred dollars(55 L, �n ❑i,as owner of the property, NEW RESIDENTIAL ELECTR SQ.FT, STORIESIYPECONSfRUCTION p perty,or my employees with wages r thele sok sol.&c. 0Kion,wU I do the Wake..work and the ionslrudureh not Intended or offend for O doe(es notapkq to atr owerf property Cobuilds Contraor License taw whoit not apply to himself through improvnded that who donsuchwork hinoelforthrough hisownemployen,provided that mels OCC.GROUI' RIS.UNFI'S improvements arc not intended oroffered formic.If,however,thebuilding or TOTAL: improvement lswld withinone)carolcompletion,theowner-bu0derwilluve tl( then of proving that he did not Wild or improv,for purpose ofaale.). QTY, PLUMBING PERMIT.;' ;,_FEE" FLOOD ZONE APN Lf L as owner of the property,am exclusively contracting with licensed contractors to construct the project(See 7014,Business and Profedfooa Code: ppRLtiSUANCE' 160 . The Contractor's Limas law does not apply to an owner of propertywho ALTER-DRAIN kVENT-WATER MA)) Wads or improve thereon,and who contracts for such p(ojects with a ' D ` I! p FEE SUMMARY; cgnt(actods)licensed pI.pursuant to the Contrador's License L - BAIX FLOW PROTECT.DEVICE LJ I am exempt ynder Sec. B k P C for thio mason FEES DRAINS FIAOR'ROOF,ARLA,COND, SANITARY Y N� Owner Date ` REC[ll'PN WORCOMPENSATION DECLARATION PO(Il1WSI'EIZ'IRAP SCITODLTAX Y N E31 hereby affirm that chat I have a certificate of consent to wmre lf- mr ,ora •L9 D RECEIPT M certiflcateofWorken'CompensationlmuranreoramdifledropytAereof(Snc, GAS EA.SYSTEM-]INC.0 OUILLTS PARR FEE y N 3E00,UbC.) - ]2ECEBN Policy p CAS RA:SYSIPM-OVI'R a(EA) •. - Cam y RUILDING DIVISIONITES yC,e�rtified copy Is hereby furnished: �ZCedified copy is filed with the city Inspection division. CREASE/INDU57T2L WASTE INTERCEPTOR PLANCHECK FEE, CERTII:l Tn OFCXEMPTIONFROMWORKERS' GREASE TRAP PAID 1 COMPENSATION INSURANCE SEWER-SANITARY-MRM G.200FT. Date R0001 [# (Chis section need not be completed If the permit isfor ane hundred dollars ($IBB)orleaa,) WATER HEATER w/v'rxr/pip-crR ENERGY FEE Y N [certify that in the performance of the work forwhlch this permit is issued, , I shall not employ any person in any manner w is to become subject to the WpggR SYSTEM/TREATING ` Workers'Compensation Laws of California.Date _ .PAID icant Z Z NOTICETOAPPLICANT:ILaRermaking t his Certificate of Exemption,you NEW RE4DENTIAL PLMB. Date RCcej t# should become subject to the Workers'Compesuation provisions of the Labor TOTAL: Code,you must fort hwlth comply with such provbions or this permit shall be W > deemed revoked. BUILDING •• 72- 00 W — colvsrgumoN LENDING AceneY - SEISMIC FEE a Z o tthc .,mtrwhicrcIsacomtructssued dingagenryforthepedorn� T Lo DD ELECTRIC FEE -O(' 7 O once of the work for which tM1Is permit Wlssucd(Sec.3097,Civ.C.) o V leaders Name -- - -- PLUMBING PEE F Lcndc ,Addcros QTY. �MECHANICAL•PERMIT t� FEE ' p LL' - MECHANICAL PGB OW Iced.Iamlhavemad mply withal]citynand dcoundate that the ordinaces aeddatelaon /I Iscorrect. agrceto complywith alldtyandcouhomas representatives and date PERMIT ISSUANCE ��_�V FEE$]r(11 D' r } W relating lobullding construction,and hereby authorlu rcpressntativea of this fps--�i—i•/E=1 3,��• ' Z L.;al.11ll o entero the abovnmanliered property for inspection purposes. ALTER OR ADD TO MFCH. e)a e to ve,IndcnWfy and keep harmless the City of Cupertino Date RCCCIPI# (') Ilides,' dgments,mstsand npenses which may in any wayaccrim AIRHANDUNGUNIT(TO10,000 ) SUBTOTAL: ut Id Clty nconsequence of tM1 gof this permit. /�fJf�J v AIRFIANDLINGUN(((OVER1B," ) • CONSTRUCTION TAX r9u7ee�.. /odS-9/ - CONSTRUCTION TAX PAID: S' nature of Appacan ontrador Date EXFIAUSSHOOD(W/DUCT) RDOUS MATERIALS DISCLOSURE CHI the applicant or future building occupant store or handle hazardous HEATINGUMT(TO100,00011711 - Date Recei [# material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the Iie❑.ItYnnd Safety Cod,,Section 25532(.)7 + HEATING UNIT(OVER 100,000 RTI D - -TOTAL: Will the applicant or❑future building occupant use equipment or devices Z VENTILATION FAN(SINGLE RESID) - 00 ISSQANCE DATE , which emit hazardous air contaminants as defined by the Bay Are.Air �k IM Quality Management District? - BOILER COMP OFR'OR 100,0(0 BTU) P{R have mad the hazardous materials requirements underChapter6.95 of BOILER-COMP(OV[R100,000BN) I :1 the CalilornW Health kSa(ety Code,Sediom 75505,25513 and 255M. UIDs { �, understand that 11 the building don not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT responsibility to notify the occupant of the requlrcments which must be met prior to issuance of a Certificate ofOnupanry. N�W Qfi( • Owric'miithodzed agent Data C ISSUED gY: TOTAL: - OFFICE COPY