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25653 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY CITY OF CUPERTINO PERMIT No. (^ BUILT)ING DIVISION APPLICATION/PERMIT PLUMBING. IDE NICC v BUILDING PROJECT IUEM'IFICATION 53 BUILDING ADDRESS: /Jf� ` / SANITARY NO. A1PPLICATION`SUBMITTAL DATE DL ^ 0 ll UNIT# LOT 1 b�1yg11 OW NAME: P NE: C CT 'SNA yIC 0N/C �� / Lt � •J �� NIC CONTROL# A HITECT/ENGINEER:. IV LIC NO: A RESS: SOL 7 ❑ Et CONTACT: PHONE: QTY. BUILDING PERMIT INFO ELECTRIC PERMIT FEE BLDG ELECT PLUMB MECH PERMIT ISSUANCE ❑ E] ❑ LICENSED CONTRACTOR'S DECLARATIONppPLIANCES-RESIDENTIAL LOB DESCRIPTION Q9�z I hereby grim that l stn licensed underpmvisionsofChapter9(commmcingwith Vr 00 Section 7")of Division 3 of the Business and Professions dmyl' setsr PANELS tF< full fnrceand effeytl ' /1 e-1 Rl'I� `� IIP TO 200 AMPS Vjn.� � F pl Li ansa Class l� Lia#` P-�7 y am Cuba"or 201-I000 AMPS Z O,Z ARCHITECTS DECLARATION OVER 1000 AMPS r SQ.IT.FLOOR AREA 8/SQ.FT. OZ-0 I understand my plans shall be used as public records. ry�.. SIGNS ELECTRICAL 77 7) 0 N Licensed Professional _ PJC�u OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC. I hereby affirm that I sm exempt from the Convectors License Law for the t W 3O rFit following reason.(Section]03 L5,Business and Rofessions Cade:Any city or county TEMP.METER OR PoLE INST. / �i a� which requires a permit m construct,alter,improve,demolish,rn repair bay structure f/G prior r its issuance,also requires theapplicant forsuth permit b fileasigned statement POWER DEVICES DATE that he is licensed pursuant to the provisions of the Connbcrrs License Law(Chapter ax�o 9(commencing with Section 7")of Division of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION orthat heis exempOherefmmand the basis for thealieged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES y�Q Section]031.5by any applicem for a permit subjects the applicsarao a civil Jimmy of not more than five hundred dollars($500). NEW RPSIDRNTIAL ELECTR S 11I,asowneroftheproperty,ormyemployeeswithwagesastheirsolee mp mafion, Q'PUL STORIES TYPE CONSTRUCTION ywill dothewons Code: he Com orter'nLnense Law does nor 11144,Business and Professions Cade:The Contractor's License Law does no[apply r an owner of progeny whobuildsorimproves thereon,and whbd.such work himselforthrough his OCC.GROUP RES.UNITS conemployees,providedthat suchimprovemeats arcnotimendedi rofferedfrrsale.If, however,the building or improvement is sold withinone yearoftompletion,the owner. TOTAL builder will have the burden of proving that he did not build or improve for purpose of sale.). . PLUMBING PERMIT FEE ❑ I,mownerofthepmpeny,mnexclusivelyconvatlgwithlicensedconvactorsto QTYFLOOD ZONE ATN' nnmuct the project(Sec.7044,Business and Professions Code)The Contractor's PERMIT ISSUANCE License Law does not apply to on owner of property who bui Ids m i mproves thereon,and who contracts for such objects with a conttactor(s)licensed pursuant to the Communes License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY ❑ I am exempt under Sec. ,B&P C for this reason OUTSIDE FEES BACK FLOW PROTECT.DEVICE SANITARY Y N Owner Date RECEIPT# DRAINS-FLOOR.ROOF,AREA,COND. WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N ❑ ers ComrematinInsuance orifiwm and Copy thereof Lab C.)c which FIXTURES-PER TRAP RECEIPT# Workers Compensation Insurance oracettified copy thereof(Sec.3g00,Lab CJ which PARK FEE Y N covers all employee's under this c RECEIPT# porter GAS-PA.SYSTEM-1 INC.40UTLETS Policy N BUILDING DIVISION FEES Company ❑ Cerifiedeopyisherebyfumished. GAS-EA.SYSTEM-OVER 4(FA) PLANCHECK FEE ❑ Certified copy is filed with the city inspection division. GREASWINDUSTRL WASTE INTERCEPTOR GRADING FEE CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE COMPENSATION INSURANCE (This section need notbe completed ifthe petmitis forom hundreddallma($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE or less.) Icertify that in the permmmnec of the work for which this permit is issuttS l shall WATER HEATER W/VENTIELECfR not employ any person in any mbtmer sec as r become subject r the Worker% PAID Compensation laws of California. Data WATER SYSTEM/IRRATING Date Receipt# O z Applicant 0. NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL: DO become subject in the Worker's Compensation provisions of the Labor Code,you must LLL^^^ forthwith comply with such provisions or this pemdt shall be deemed revoked. BUILDING FEE Ili 0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE Vz Ihereby affonn that there is a coasvuction lendingegrncy for the performance of TOTAL: ELECTRIC FEE O1-� tNauru work far which this permit is issued(Sec.3097,Civ,C.) F-' Lenders Nae u" Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FE Lk1 co I terrify that 1 have read this application and state that due above information is MECHANI AL 0. correct. l agree m comply with all city and county ordinances and state laws relating r PERMIT ISSUANCE V) building conswctioa,and hereby authorize representatives of this city tp enter upon the CONS TI TAX V y above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. �i (We)agree to save,indemnify and kes mord.the City of Cupertino against liabiliti rnts,costs expenses ay in any way accrue agaitutsaid City AIR HANDLING UNIT(TO 10,000 CFM) e of the gof th' O AIR HANDLING UNIT(OVER 10,000 CFM) Signaw Ap tumSVC rr EXHAUST HOOD(W/DUC'D PAID HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTM Date Receipt# Will the applicant or future building occupant erre or handle hazardous material HEATING UNIT(OVER 100,0010 BTU) TOTAL: as defined by the Cupertino Municipal Cade,Chapter 9.12,and Ne Health and Safety Code,Section 25532(x)] 11 Yes El No VENTILATION PAN(SINGLE RESID) ISSUANCE DATE Will the licanmrfuturebuildin tune Inrdeviws whichemit BOILER-COMP(3HP OR 100,000 BTU) g� gy B pp d by then Area it Y� P9 hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COW(OVER 100,00(1 BTU) District? ❑Yes ❑No NEW RESIDENTIAL.MECH.—SQ.FT. �ffl �/$� I have read the hazardous materials requiremems under Chapter 6.95 of the OCT 20 g^Y„V3 Health&Safety Code,Sections 25505,t it is and responsibility l ity to nmud that C�IY VI- UUf CK� CaliforniaCthe building does not Safety Code have Sections i tenant that itis my responsibility to notify the V occupant of the requirements which must be at prior to issuance of a Certificate of ' Occupancy. r .� Owner or awharized agent Oar ISSUED BY: OFFICE