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27723 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPEPeaMITNo. 27723 BUILDING DIVISIONSION APPLICATION/PERMIT PLUMDI ECHANICAL BUILDING PRNG-MOJECT IDKNTIFICATION BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMMALDATE ( D 1 ,Jg 11 /♦� p V��p1Lw�s L.//� UNIT LOT Mia,. �Q RSNA ONQ l I�ll� a LIC NO: Iv si ;^Arr ��a -e LIC��' a2I S r4 N/C CONTROL# -�ARCHITECT/FNGINF.ER: LIC NO: 1 �•���Ir O"V`� V\' (NAElC NTACT: PHONE: f �J 6 QTY• ELECTRIC PERMIT FEE BUILDING PERMIT INFO V lG C�Yo r I G gOd 65e' 99oS PERMIT ISSUANCE BLDG ELECT PLUMB El LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL El ❑ 00.'Z I hereby affirm that l am licensed underpmvisiansofChapter9(commeacingwid, JOB DESCRIPTION J400T� Section 7")of Division 3 of the Business and Professions Cade,and my license Is in ppN©•S TUU full farce and of ret. /♦, ��� d Date o a• Con. 1 IIP T0200AMR9 ��// % rFii= Dale Conuac-�y �`��,%40T 201-I00OAMPS ZOvr�' ARCHITECTS DECLARATION OVER IOOOAMPS SQ.FT.FLOOR AREA I;/SQ FT. oza O 1 understand my plans shall be used ea public records. ry_ LL ¢Y j Lensed Profess mou SIGNS ELECTRICAL C�Wu OWNERBUILDERDECLARATION SPECIAL CIRCUIT/MISC. 0 W U I hereby ME.that I mn exempt from the Contractors License Law for the F0 following reaven.(Secdon7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST. �Oy.¢.1 which requires a permit m construct,Marc.improve,demolish,or repair any structure rna� Arun[.its issuance,also agmres the applicant for such Penni[a file.signed statement POWER DEVICES C 0 that he is licensed pursuam a the provisions of the Convector's License Law(Chapter d o�' 9(commencing with Section 7")of Division 3ofNe Business end Professions Cade) SWIMMING POOL ELECTRIC ul—m or that he is"'rapt therefrom and the basis for the alleged exemption.Any violation of VALUATION Section 7031,5 by any applicant far.permit subjecn the applicne 1.a civil penalty of OUTLETS-SWITCHES-FIXTURES 0 not more than Five hundred dollars($500). ❑ I,asownerofthepropeny,ormyemployeeswithwagesaztheirsolewmpensadon, NEW RESIDENTIAL ELECMM _SQ.FT. S .S TYPE CONSTRUCTION o. will dotheweak,and the s[mcmreis not mondedoroffered forsale(Sec.0044,Business and Profeside s Code:The Commmors License Law does n.[apply to an owner of property who builds arimpmvesthereon,andwhodoessuchwmk himself.,thaeghhis own employees,pavided thitsuch:mpavement:are not intendedoroffered forsee.If, ROUP RES.UNITS however,the building orimprovememt is sold withinone yeareaftempletied,theowner- builder will have the burden of proving that he did not build or improve for purpose of TOTAL: sale.). ❑ I,asownerofthepaperly,amexclusivel,contractingwi[hlicnsedcontrecrorsto QTPLUMBING PERMIT FEE FLOODZONE APN omtruct the paper'(Sec.7044,Business and Professions CodeO The Contractor's License Law doesnorapply wanownerofpropeny whobuildamimprovestherwn,and PERMITISSUANCE who commea s for such projects with a contactor(:)licensed pursuant o the Commences License Law. ALTER-DRAIN&VENT-WATER(FA) FEE SUMMARY ❑ I am exempt under Sw. ,B&P C fm this reason BACK FLOW PROTECT.DEVICE O TSIDE FEES Owner Date SANITARY Y N WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND, RECEIPT# Thereby affi,m thetl have a certificate attain...I to self- SCHOOL TAX Y—N msure,or Lab C.)c which FIXTURES-PER TRAP RECEIPT# Wnrkers'Compensetinn lneurance.racertifiedcopy tbereof(Sw.3800,Lab CJ which PARK FEE Y N_ ars all a yegC Policy# O GAS-EA.SYSTEM-1 INC.4OUTLETS RECEIPT It companyBUILDING DIVISION FEES F9 Cenifed copy::hereby famished. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE ❑ CertifiW copy is"led with the city inspection division. GREASF1NDUSTRL WASTE INTERCEPTOR GRADING FEE CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP COMPENSATION INSURANCE SOILS PEE (This section need not be completedHNe permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. or less.) ENERGY FEE Icertify that in the performance rule work fmwhich this permit is issued,IAM] WATER HEATER W/VENT/ELECTR not employ any Pearson in any manner so as to become subject to the Workers' PAID Q Re .z C.mpenearinm Lawria Celifomia. Data WATER SYSTEMMI TING Date ceipt# O Applicant zNOTICE TO APPLICANT:If,after making this Cenificate.f Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. rn became sabjem to the Worker's Compensation provisions of Oso Labor Code,you must TOTAL: ai �^ forthwith comply with such provisions or'his permit shall be deemed revoked. BUILDING FEE pW,ar A CONSTRUCTION LENDING AGENCY SEISMIC FEE Z I hereby affirm that there is.construction leading agency for the performancea U O Me work for which this permit is issued(Sec.3097,Civ.CJ O� ELECTRIC FEE Lk. Lender's Name 0 U Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE W I vanity Net 1 have reed this application and state that the above information a 61 correct.I agree to comply with all city and county ordinances end state laws relating to PERMIT ISSUANCE MECHANICAL FEE DO building construction,and hereby auNm:u tepresimmuses.fthis city a eaterupon the U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX (We)agree to save,indemnify and keep harmless the City of Columbian against liabilities,judgmrnts,coats and expenses which may in any way aceaeegvnstsaid City AIR HANDLING UNIT(TO 10,000 CFM) inconsequent hag ringatlaispermit. s. 1 LR b AIR HANDLING UNIT(OVER 10,000 CFM) rgnamre of Applicata/Contractor _1 Dew EXHAUST HOOD(W/DUCD PAID HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt# Will the applicant or fume building Occupant store or handle hezardoos material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL: Cade,Section 25532(a)9 ❑Yea 0N VENTILATION FAN(SINGLE RESID) Will the upplicnwrfutare buildln oeeu amt use BOILER-COMP(3HP OR 100,0(10 BTU) ar•'. ISSUANC8 DAT8 herniations air conominn¢as defined by the Bay Area NAir'Quality Management� District9 BOILER-COMP(OVER 100,000 BTU) P Q 9(J ❑YeLlrol, ❑No NEW RESIDENTIAL MECH. SQ,pT. �E V +x796 read the haeardous materials requirements under aspmr 6.95 of the eelth&Safety Code,Sections 25505,25533 and 25534.1 understand that l/h G�r�f ar 1 i g does not currently have a tenant,that it is my respons:b00y m notify the the requirements which mus'be met prior to issuance of a Certificate of drunied.gem Date TOTAL: ISSUED BY: OFFICE