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28243 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. APPLICATION/PERMIT PLUMBING-MECHANICAL BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 28243 :I I BUILOINGADDRE SANITARY NO. APPLICATIONSUBMTITALDATE l �7 s1TS's L( O UNIT LOT I ?H IJP:_ CO OR'S N L N N/C CONTROL. r Vl UI/b ARCHITECT/ENGI� LIC NO: A D ❑ ift 1, CONTACT: PEON -- SU� 4 QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO _337© PERMIT ISSUANCE BLDG ELECTPLUMB MECH ❑ ❑ ❑ L ENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL ❑KZ Ihereby offinnthat l am limmund underpmvisionso(Chapter9(eommencingwith JOB DESCRIPTION �W OO❑ Section]000)of Division 3 of the Business and Prafessio s Code,and my license is in pgry6Uq 7zzU Lcforca ande4 t. pa,24] Licen N UP T0200 AMPS . vl?y Date Canlruc 201 1000 AMPS F=Z RCHITECTSDECLARATION SQ.IT:FLOOR AREA Ii/SQ.FT. Z y^ OVER UM AMPS P _02 O•.,O I understand my plans shall be used as public records. m 875.W LsenaeJ Itofeseianul SIGNS ELECTRICAL 4 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC, X0 1 hereby affirm that 1 sm exempt from the Contractor's License Law for the ly 3 0.m following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METE-R OR POLE INST. which reforms a permit to constrvot,altar,improve,demolish,or repair any structure Nab prior to its issuance,also requires the applicant for such pemdt to file a signed statement POWER DEVICES i0 that he is licensed pursuant to the provisions oflhe Contractor's License Law(Chapter p 9(commencing with Section 9000)nf Division 3 ofthe Budricamand Professions Code) SWIMMING POOL ELECTRIC VALUATION p .,to omhat he is cxempOhomfinm and the basis for the alleged exemption.Any violatomid i Section 7031.5 byany applicant forapencon soh t the Ic tmacivil penalty of OUTLETS-SWITCHES-FIXTURES t more than❑ve hundred dollars($500). Jw s pp i an M m n❑ I,asawnerofthe ro n NEW RESIDENTIALELECTR _SQ.ET. �3 p peye,is..ortudeeswithwegesasthe(sole compensation, STORIES TYPE CONSTRUCTION will dothework,ands: o Cmuisro im kende awdoforsale(Sec.]0an Business and Professions Code:The Conthectors License Law does not apply if an owner of propertywhobuildsorimprovesthereofanments notinworkoraffmdforsugh his own empluyees,pingor i provehimprovemwithin nor[ouroednroffered the own If, OCO GROUP RES.UNITS however,the buildingofimprovementissold withinoneyearorimproeImtheowner- builder will have the burden of proving that he did not build or improve Impolitical of L' sale.). Cl I,asawnerofthe property,ton excleadvelyconuacting with licensed contractorsm QTY. PLUMBINGPERMIT PER FLOOD ZONE APN construct the project(Sec.7044,Business and Professions Cade:)The Contractor's License Law does not apply to an ownerofpmpeny who builds or improves thereon,and PERMIT ISSUANCE who contracts for such projects with a emmuchu(s)licensed pursuant to the Contractor's License Law. ALTER-DRAIN&VENT-WATER HbU FEE SUMMARY ❑ I an exempt undo(Site B&P C for this rensan BACK FLOW PROTECT.DEVICE OUTSIDE FEES OwnerSANITARY YN Dote DRAINS-FLOOR,RCOp,AREA,COND. RECEIPT# WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN ❑ thereby affinlnhat(have s cenifiwla of cmnsem wself-insure,or a certi,cam of FIXTURES-PER TRAP RECEIPT# Workers7mirpensation lnsumnce or a cenified copy thermf(Sce.3800,Lab C.)which PARK FEE Y N laversallemp`Oyp9 a.mdWk pgrvy GAS EA.SYSTEM-1 INC.4 OUTLETS RECEIPT# Policy# BUILDING DIVISION FEES Company GAS-EA.SYSTEM-OV 4(G) PLpNCHECK FEE ❑ Cenified copy 1s her�mhe cityiN ❑ cenified copy is filed with the city inspection division. 6Pf-ArVNVUSt:1,VAa-2Nj1j�CtPyR GRADING FEE CERTIFICATE PE COMPENSATION EXEMPTIONMOMWORKERS'fi A ETR SOILS FEE COMPENSATION INSURANCE (This section need the completed if the permit is forone hundred dollars($ or less) IW) l SEW R-SA TA Y-STO FT. ENERGY FEE _ I certify that in the performance of the work for which this permit is issued,l shall WATER L not employ any person in any manner so as to become subject to the Workers' PAID 7-. CCompeunsation Lawsaf California. Date If"sl1h STEMITREATINGApplicDem ReceiplN nt zO NOTICE TO APPLICANT:ff.-11 making this Cenificale of Exemption,you shou6 NEW RESIDENTIAL PLMB. SQ.FT. TOTAL: FV) become subject to the Worker's Compensation provisions ache Labor Code,you most ai j forthwith comply with such provisions or this penrdtshall be deemed revoked BUILDING FEE ala CONSTRUCTION LENDING AGENCY SEISMIC FEE 7-. I hereby affirm Net there is a concoction lending agency for the performance of V O the walk for which this permit is issued(See3099,Civ.C.) TOTAL: ELECTRIC HE {L p LenJers Name O LenJerFE s Address QTY. MECHANICAL PERMIT FEE PLUMBING E U 1 certify that I have read this application and some that the above information is correct. Ingree to comply withill city and countyordinanees and state laws relating to PERMIT ISSUANCE MECHANICAL PEE building construction,and hereby authorize representatives ofRhis city toener mann the U 7 above-mentioned property for inspection purposes, ALTER OR ADD TO MECH. CONSTRUCTION TAX •^. (We)agree to save,indemnify and keep harmless be City of Cupertino optical liabilities,judgments,costs andexpenses which may in any way accrue against said City AIR HANDLING UNIT C70 10,000 CFM) I.consequence of the grunting of this permit. AIR HANDLING UNIT(OVER IO,alo CFM) Signature of ApphcanVCnntmctor Date EXHAUST HOOD(W/DUCT) PAID HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 10),000 BTU) Date Receipt# Will the applicant or future building de,Cap store or handle hazardous material Code,Secio the Cupertino Municipal Code,Chapter 9.12,and the Health and Sufery HEATING UNIT(OVER IOO,1Xq BTU) TOTAL: Code,Section 25512(e)1 El Yes No VENTILATION FAN(SINGLE RMID) Will thea applicant BOILER-COW(311P OR 101.000 BTU) ISSUANCE DATE pp goccupantuseequipmentordevicee which hazardous air centamimnts as defined by the Bay Amu Air Quality Management BOILER (OVER 100,000 BTU) q ielridl "1 ❑Yee No NEW RESIDENTIAL MECH. SQ.FT. I hall tea aeardous malennls re ants under heater 6. Uf the Jut CalifomiaH & for Code,Section 0 5533 and 34. 1 reread the �if the bu' does m currently hav et it is espon ty to notify the V / ' of a uire�ea s a met prior Certifimen of V oe�a nay. h ramhnrizetl age Date TOTAL: ISSUED BY: OFFICE