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25553 APPLICANT TO FILL M INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUDAI NG-EI,h.CIWDAL I PERMIT NO APPLICATION/PERMIT PLUMRINIi-MECHANICAL 25553 BUILDING DIVISION BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS:A 1/.'.�� I SANITARY NO APPLICATION SUBMITTAL DATE: 10 S' 1 1 I I f 1 )— \ ©• •UNIT1a1 1 LOT a F-�]Ap��►�/��/'/'� .&N -e CII�/ V O I/ 00 \r I CNO I N/C � TROI.q - i ARCHI'ICCI'/ENGINEER EIC N(1 1 HE$$.LI SO. a� � { - ❑ CONTACT: PHONE: QTY. 11L� ���'I'I'IJJJ��\ (QTY. ELECTRIC PERMIT FEH � BUILDING PERMIT INFO 9E] ELECT Lp UMB- MF❑CH PERMIT ISSUANCE ZLUMEJ LICENSED CONTRACTOR'S DI:CLARAPnON I APPLIANCES.RESIDENTIAL! I JOB DESC ION pocy Iberehy affirm lhm lnmlicensed underprmvmsmonsofChupser9(commemm�g with 0 a .100 Section 71000)of Division 3 ofthe Bminess and PmPoSsions Code.and my license is in PANPys qq'Us.. ftiBfgreeandeffect. FZyUj Licene Class Lmc.4 UP TO 201)AMPS may Date Contract, 1201-I"AMps y0yy, ARCIIIIEMSDEC1ARATION COVER IM AMPS SQ IT FLOOR AREA $/SQ FT 0 Z'-' I understand my plans sMll based u public records Q— J Licensed Profc>,monal (SIGNS ELECTRICAL i OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. %O,U 1 hereby affirm that 1 ar exempt from the Contmcfor's License law Battle I{n+1 0a following..an(Sscuan703L5,Business and Professions Code.Myciry or cowry TGMP.MEI'ER OR POLE INST. �-.l which requires a permit in construct,alter,improve,demolish,ar rtpev any awcwre dd�Q� pnonn its n>uence,also rcyo'ties iMe applicant forsuch permnro rleestgned stn¢mem POWER DEVICES v�0pm tai he is Tmerold pursuunuothe pmvismns of the Cnnvncmr's License law(Chepterl (SWIMMING POOL ELECTRIC I t'—'� II i N d Xca o(cro marring with Section 900()of Division 3of the Ermines,and Prefessmas Code) I p _ TER VALUATION Ft—fin nr Net M1e is eaempnherefrom and tM1e ba+u 4n the allegedeaempuon.Any violation of Of1TLF.TS-SWITCI3E5FIXTl1RES Y)V� V� � � � 1 FyQ Section 7031.5 by any applicant for a permit subjects the appheant to a civil Penalty of E R l Sa net canoe than five hrndmd dollars($500) 1 NEW RESIDENTIAL ELECfR S W m ❑ I,a,ownerofihepropcny,ormyemployee swnhwngesasthet(rsolecompensnuon, I I C TYPE CONSTRUCTION ter will do the work,and the stmcmare is noumendedoroffered forsde Sec.9014.Business and Pmlession>Cale.The Contractor's License Law does not apply to an owner of I property who bm Ids m trprov a thereon,and who d oes such work hi rmtsa f m through h is empbyces,provided that'such tmprovercmsaronot mmeadedoroffemd forrack.If. 00C.GROUP RES UNHS bawcver.the buddingonmprovereca is sold within one year ofcompletion,the owner. I TOTAL: budder will have the burden of proving that he did not build or improve for purpose of +0 IQTY.I PLUMBING PERMIT FEE FLOOD ZONE APN ❑ Las the prelcO(S aped F1. exuce.el ad Profetmgwithlicensed Comment's onto nmense the prgec't(Sec oano Business and y who builds Coded The PERMIT ISSUANCE License Laws«snot apply acts nownerofprctood wersedpudrimprovu Nercon,and whoa Law. Much prnlectswnM1 atxmvactnrts7li.erred pursuant to Convectors ALILFR-DRAIN&VENT-WA'IER(EA FEE SUMMARY Law. 1 PEL SUMMARY ❑ I am exempt under Sec. B ffi P C fm this reason BACK(TAW PROJECT.DEV ICI? I OII"1-SIDE R!CS SANITARY Y N Owner 'rte RFCEIPTp DRAINS-Fl.00R,ROOF,AREA,COND W❑urke nCCamp e�anlmmMiwrerauracan red oaPSY harenfRSecu700,LabC l which ) 1, pill PBR'IRAP /`-i — ��PARK FEE AX YfCPmITa N Covers Ilemployee'e under this pcomn. I IGAS-FA.SYSTEM.I INC.4 OUTLETS �`Ip-- BUILDING DIVISION FEES PaT�y a Co.,. — - IGAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE ❑ Cemrcdcopyaberebyfummshed. ❑ CCmrW copy is file)wroth Ne cry mspecdon tlivision (+RFASB(INDUSTRL WASJ'F:INTERCEPTOR GRADING 193E CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FIDE COMPENSATION WSURANCE (Ibis seauonmced not be completed tithe perm is for one hundred dollms($100) I SEWER-SANITARY-S'I ORM F,A.200Ff. ENERGY FEE or less.) I certdy that in the Performance of the work for which thmspnmisss issued,Ishall WATER HEATER W/VENT/F.LECTR not employ any person in any manner so as to become subject to the Worken' ---- SAID � z Appfewttinn laws of Cuhfomia. P-- WATER SYSTEM/fItEATING I — — Dare Receipts NOTICE TO APPLICANT:If.after raking this Certificate of Exemption,you shoulJ NEW RESIDIiNTIAt.PLMB. SQ Ff. TOTAL: F' berme subject the Worker's Cnmpensabon provisions of the Labor Ctde,you must ••"�" , forthwith comply with such Provisions or this permit slWl bedeemed invoked. I (BUILDING FEE. W (� CONSTRUCTION LENDING AGENCY (SEISMIC FEE I hereby nfrom that them is a construction lending agency for the performance of U O the work far which this perdt is hared(Sec.3097,Cr.C.) AL ELECTRIC PEF. Lenders Nam- U — -- OLender's Address QTY.( MECHANICAL PERMIT FE I PLUMPING FEE U 1 certify that 1 have read this application and state that the above information is 'a" 4 W coral. l agree to comply wnhall city and countymdmanceeandstam laws relating In PERM IT ISSUANCE MECHANICAL FEE ybuddmngcnrwnmon,and Hereby arthanu rcprexn0uves ofNismryto enter upon the I CONSTRUCTION TAX I, U Z, u ".am Progeny for impemio ALTER OR ADD TO MECIL ( agree too save,andemmfy d keep harmless the City of Cupertino against Imbd es rents, spande swhich may inanywey accrue agumst said Cary I I AIR HANDLING UNFTOG 10,000CIM) in uceof rantca ft ,pemd. AIR HANDLING UNIT(OVER 10.00(1 CFM) gneture of Applmanr/Contractor Date EXHAUST I100D(W/DUCTj PAID HAZARDOUS MATERIALS DISCLOSURE I HEATING UNIT(TO 100,000 BTU) Dar Resetpta I _ — WilllhcnppLcnntrr lrmre buildingoc cu paitsmre ao handle harrdous arsenal TI-A'I'INC UNIT(OVER 100,0otl BTU) as defined by the Cupertino Municipal Code,Chapter 9.12,end the Health and Safety Code,Section 2M32(a)7 ❑No VENT ILATION FAN SINGLE SINGLE RESIDI Will(Mee P bcwuafuwre u¢e gwpmen Inrdevicee which emit BOILER-COMP1311P O100,0001311D A yy Sa NCE DATLY bmsrdors air commonanss as defined by the Bay Area Air Quality Management I BOILER-COMP(OVER 100,000 BTU) i gip 151993 �Dtann7 ❑Yes ❑No I NEW RESIDENTIAL MECN SQ Ff. 1 have read the hevaNma rnam",rcgmrcmenta under CM1npmr fi.95 of the I CITY Ur UUren I uvv California Hrlth&Safety Code,Section,25505,25533 and 25534. 1 undersrnd Nat tithe bu0d uit ilm+not eurten0y have n mnan6 that it is my respnrtbiliry to notify the C) occupant of the requirements which Most be met pnm to issuance of a Certificate of Occupancy. Owner muallumard agent Dam I TOTAL: ISSUED BY: OFFICE