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25043 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OFC P CUPERTINOyoJIL" PERMIT NO. O y APPLICATION/PERMIT 11,1111 Z; mNCxANIGAI, BUILDING DIVISION BUILDING PROJECT IDEN"I'IFICATION �+ ABUILDINGAII Ik aITM LOTp SANITARYNO. APPLICA'DONSUBMITTALDAT PHONE: C NTRACIOR'S MIi: LIC NO:c„� N/C CONTROLk : LICNO: DRESS: w� ❑ !/aL±© ISIS4Ae CONTACT: PHONE: QT-Y. ELECTRIC PERMIT FEE BUILDING PERMIT INFO BLDG PLUM MECH PERMIT ISSUANCE LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL py Ihereby affirm that l am Imensedunder provisionsofChzpter9(commencing with JOB DESCR ION Section 1000)of Division 3 of the Business and Professioru Code,and my license is in PANELS Q V F full fire,and eff rFiaQy DoleLi.ns Cl-ss Contractor // G UP 201 T0200 AMPS 1000 AMPS ZO Z'' ARCHITECTS DECLARATION OVER 1100AMPS SQ.Fr.FLOOR AREA $/SQ.Fr. OZ-0 l understand my plans shell h usW ss public rtcmdx. <H F w SIGNS ELECTRICAL QYotj LicenueJ Professional XOyUK OWU O,I notcUILDEern he CRATION SPECIAL CIRCUIT/MISC. 1 hereby affirm that I am exempt from he Contractors Liana Lew fm the FO¢ following reason.(Section 7031.5.Business and Professions Cade:Any city or county TEMP.METER OR POLE INST. which requires a nermit to construct,alter.improve,demolish,or repair any sbvcture s Y7 prior to its issuance,also requires the applicant for such permit m file a signed statement POWER DEVICES 0 p that he it licensed pursuant in the provisions of the Contractors License Law(Chapter ano4 9(commencing with Section 7")of Division 3 of the Business and Professions Code) SWIMMMG POOL ELECTRIC VAWATIO���Nppp yKj^,� or h7031.5 by Ncrefrom and the besis l Objects is the exemption.w Any civil Penalty of LETS-SWITCHES ITCHES-FIXTURES [}. -� a Q not I'1(131.5 by any dyed doll I'a$permit xubjecrs the ultplicmt to a oivil penalty of ta` Sp not more than five hundred Jnllws($500). NEW RESIDENTIAL ELECIR _SQ.FT. STORIES TVPECONS'IItUCTIOt KFo ❑do wrk.and the cracture syemployeeswi@wagesasthe(solecompensation, will do lesions and e#s o Contractor's Lic rve a w ed does not apply 7(M4.Business of r and professions s Id.,e:The Coffiein ...item,Law fi not apply tom owner isAL prnperywhnhuildcurimprovea therms,and whndce...M1 work himselforthrough his — own employees,provided Nal such improvements are om mendedoroffered forsale.If, 0WCOUP IT$ however.the building or improvement is said withinone years(comthe e owner- ® Y V J OJ f;—builder will have the burden of proving that he did not build or improve for purpose of VVVV u aElc.). of TY. PLUMBING PERMIT F LOOD ❑ Les owner Property,amexclusisand nnassionsCosleenaWmnwraorslo Q DATA ^P" construct the project(Sec.704,Latano Business end Professions CWe:)'fhe Contactors License Lewdres not applytomnwnerofpmpcnywho builds orimpmves thereon,and PERMIT ISSUANCE — Uteri,Law. forsuch projals wiNacontnctor(s)li<ensW pursuantmthc Contractors Liccns Law. ALTER-DRAIN&VENT-WATER(EA) rpi � FEE SUMMARY ❑ I um exempt mdc,Sec. ,B A,PC for this reason BACK FLOW PROTECT.DEVICE ass—a' UCODE FEES SANITARY Y N Owner Dare pRA1N5FLOORROOFAREA,COND. RECEIPT'# - . , WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y 01h"chyeffirm that l have a certificate of consent to self-insure,or a certificate of X'1'URES-PERTRAP RECEIPT# orkeri Compensation Insurance or a cenitiedcopy lhereof(See.3800,Lab CJ which PARK FEE Y N vin all employee's under This permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT# Policy# NOD ISIONFEES Company GAS-EA.SYSTEM OVER 4(EA) PLANCI IIiC O ❑ Ccnified copy is hco by famished. ❑ Certified copy is Bled with the city inspection division GREASEgNDUSTRL WASTE INTERCEPTOR GRADI CERTIRCATE OF EXEMPTION FROM WORKERSGREASETIOP COMPENSATION INSURANCE a�a (This section tumdnot bemmpleted Hire pumil is prom hundred dollers($100) SEWER-SANITARY-STORM FA.20IFF. ENER YFEP, V or less.) I certify that in the pMo.ceofthe work for which this permit is issued.I shall WATER HEATER W/VENT/ELECTR nm employ any person in any maturer so as to become subject to Ne Workers' PAID O z Compeneationlawsof California. Date WATER SYSTEMf BEATING APPlicmt Date Rccci p O� z 0 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT, TOTAL: F 4 become subject to the Workers Compensation provisions of the Labor Code,you must C forthwith comply with such provisions or this permit shall be deterred!oc,.UL _ BUILDING IEE �# GQ CONSIRUCfIONLENDINGAGENCY SEISMIC PEE z Ihereby affirm that there is 4 construction lending agency for the performance of U O the work for which this Permit is i.ssuW(Scc.3091,Civ.C.) ELECTRIC F'EE Lender's Name O U Lender's Address JRFELMECHANICAL PERMIT FEE PLUMBING FEE } P.l 1 certify that I have read this application and state that the above information is vat 6, correct I agree tocamply with all city aWrounryordinmeea mrdsme lawsmlatingioITISSUANCE MECHANICAL FEE building construction,and hereby announce representatives ofifis city menterupon the L) Z .hrvonrcmometi,npeny for inspection purposes. OR ADDTOMECH. CONSTRUCT'IONTAX (We)agree In save,indemnify and keep harmless the City of Cupertino against lucid I"'ju cats is ardexpen Mich may in any way accrue against aid CityANDLING UNIT IU,tJW CFM) to conaiq gan4ng up rl. ANDLING UNIT(OVER 10,001 CFM) �� Sig are o[Apltliwm/Contr Int pate EXHAUST HOOD(W/DUC9) [Cyst+ PAID HAZARD US MATERIALS DISCLOSURE 77 JJ NG UNIT(TO too,Op B,ru) Dote Receipt# Will the applicant or future building Occupant store or handle hazxrduus material as defined by the Cupertino Municipal Civic,Chapter 9.12,and the Health and SafetyNG UNIT(OVER IOQ(gO BTU) 'RTI'AL: Code,Section 25532(x)1 ❑Ycs 0N LATION FAN(SINGLE RFSID) Will Ne upplicantorfumrehuildingaceupanl useromMenl mdeviceswhich emitR-COMP(3HP OR 100.00 BTU) ISSUANCE DATE enninw air conaminants as defined by the Bay Arc.Air Quality ManagementR-COMP(OVER 100.010 BTU)Istricf! ❑Yes ❑No ESIDENTIAL MECH. SQ.FT. A O ptg Llhave ead the hazardous materials requirements under Chapter 6.95 of the ��doo, Safety mlyode Swelhaven icro55t15,25533mrsponsi 1undcntmd NaG _ 6 does not currently hove a tenant,Nat it is my responsibility to notify Nee requirements which mxsr be met prior to issuance of a Certificate of Occupancy. C onzed agent Dale TO 1 ISSUED BY: ` �V