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24507 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE SALL POINT PEN ONLY CITY OFCUPERTINONG- 1 AI' PERMITNO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL /� /I4 J C O BUILDING PROJECT IDENTIFICATION L BUILDING ADORES �/' SANITARY NO. �APPIJCATIONSUBMITTALDATE D uaO� j� UNITp OTp `VIA.14 OWNS hyE: PHONE:-'^ CONTR R'S NAME:_• LIC NO: N/C CONFROLp Im ARCHITECT/ENGINEER: LIC NO: !a+ ADDRESS: C 'pr?.i I �+L CONTACT. PHONE: QTY. ELECI'RICPERMI'I' FEE EUILDING PERMIT INFO BLD f.LECI PLUMB MECH 1M Q� PERMITISSUANCE FLOCNg hICENSED CON'TRACTOR'S DECLARATION APPLIANCES-RESIDBM'Inh 1 QWz, HumebyaDirm thatlamlimnsedunderpmvisimsof Chapter9(commencingwith C Q1008DDFSCR I�V u100 Swim 7000)of Division 3 of the Business and Professions Code,and my ITceme is in PANELS 2t� full force and cff QV m s az Lic.p UP TO AMPS F% � erten, s Contracmr 201-1(100 AMPS �` zOv z understand my DEC TION OVER IOW AMPS SQ.IT.FLOOR AREA NSQ.FT. CZ.a1 underanJ my plans shell be used a public obs. © ' Poet::j ELECTRICAL � gq,W<�� Licensed Professional OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. X NI OLF 1 hereby affirm that 1 an exempt from the Contractor's License Law for the f,"� R t+134m following motor.(SecurrI0J1.5,Business and Professions Cuda Anycitymcmmy TEMP.METER OR POLE,NST. � • F' o,_1which requtres a permit to consumer,alter,impmve.demolish,or repair say lova tum �r/r o-E prior tail issuamc,mso rtyvires the applicant far such permiuo fileasigned sacrament POWER DEVICES W G p that he is licensed pursuant to the provisions of the Cormacors License Law(Chapter q' e 9(commencing with Section 7000)of Division 3ofthe Businessnnd Professions Code) SWIMMINGPOOLELECTRIC �AA VALUA m_w or that he is exempt thcrtfrom bas and the is for the alleged exemption.Any violation of OUTLETS-SWITCHES-FlXTHIES z,Q Section 7031.5 by any applicant for a permitsapplicant subjects the applicano a civil penalty of I�r K mnot mom Nnnfive handled d.11.,($500). NF,WRESIDENTIAL ELECfR _SQ.FT. STORIES TYPE CONSTRUCTION ❑ Los work.and the tMeiSce.701 Business yW will domework.nod the heCoreisnotTn¢nense Law does rot apply to rut Business and poilpa Professions Code:The Contractor's License Law does not apply m an owner iof s ovocrowyevacpdsorimphat suth improvemenoumasuchwded.,xRonhroughhis OCC.GROUP RES.UNITS ow ever,the yebuilding uprvvi or improvement imp is sold ntthinmeintcofromoffered hostile.If. however,willbas l the bouimprovemcntissolde did acneyem orimproeforn.purpose f saildv will have the burden of proving Net he did not build or improve for purpose of ❑ I,us ownerof@epropeny,amexulusively cnmrncting with licensW contractors to QTY. PLUMBING PERMIT FEE FLOOD ZONE Apry onsnan the pojoel(gee.7044,Business and 14ofbxsions CodeO The ContractorsppRMIT ISSUANCE i License law does not apply to an owner of property who bui TN m rt improves Noon,and whncommets for such projects withaconeracmd,l)licensed pursuant to the Cminctols ALTER-DRAIN 6:VENT-WATER EA License Law. BEA) FBESUMMARY ❑ Ism exempt under ga. ,B&P C for this reason BACK FLOW PROTECT.DEVICE O S D'FE SANITARY Y N Owner Date RF,CEIPT 0 DRAINS-FLOOR,ROOF,AREA,GOND. WORKMAN COMPENSATION OF,CLARATION SCHOOLTAX Y N I herebyaffirm that l have aronifcateofconxnt to self-insure,oraconificateof ;,%TURES PER MAP RECEIPTN Wmkers'Compenmtion lmurance orattrtified copy Hereof(Sce.JBW.Lab C.)which PARKFEE Y N_ ry nllemployce's undmhis permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT# - Fine,p BUILDING DIVISION FEES Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE IT enified copy is hereby furnished. nified copy is filed with the city inspection division. GREASFANDUSTRL WASTE INTERCEPTOR GRADING FEE CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE COMPENSATION INSURANCE ('This section need not M completed ifthe Permit is for one hundreddollan($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE or less.) I certify that in the Performameaftheworkfo whichthisperannixissued,lshal, WATER HEATER W/VENT/BLECTR nd empl ffPPLImCANI n any manner soPi to hyoyx bjwt to the Workers pq(p pcnsa- alifomia. Dom—j-p— {a7 ' irk WATER SYSTEM/TREATING Date Receipt p licuntft— z TICET ,after making this Certificem of Exemption,you should NEW RESIDF,NTIAI.PCMB. SQ.PT. TOTAL: r LO oma sacCode,you must fonM1withc such provisions or this Permit shall be dttmed.,.ked. BUILDING FEE r 4 (] CONSTRUCTION LENDING AGENCY SEISMIC FEE O V z 1 hereby affirm tom them is a conswNon lending agency fm the poromwce of TOT ELECTRIC FEE �� O ec the work for which this permit is issued(S .3097,Civ.C.) pLendeYs Name PLUMBING FEE Lenders Address QTY. MECHANICAL PERMIT FEE V I comfy that I have read this application and state that the above information is comer,l agree to comply with all city and county ordinances and state laws relining to PERMIT ISSUANCE MECHANICAL FEE t� f--' 9 V) huildingconrmetion,and hereby announce,represemmivesof this city to enter upon the ,U z above-mentioned property for inspection purposes. ALTERORADDTOMECH. CONSTRUCTION TAX (We) mom rove,indemnify,and keep harmless the City of Cupertino against liabilities,judgmenmemis andexpenxs which may inanyway accrue against said City AIR HANDLING UNIT(TO 10,0f10 CFM) in se eof the ming of this permit. / AIR HANDLING UNIT(OVER I10,000 CFM) St a ppbc_VCo p EXHAUSTHOOD(W/DUC1) PAID HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Umm RwClptp WI the applicant or future building occupant store or handle harardeus material as defin by the Collection Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 1 00.000 BTU) evis. 1=00 Alit. Coda Seai 25532(a)7 C Yes 1:1 No VENTILATION FAN(SINGLE RESID) Will theupplicantor furore building pantuuequiptmnmrdevittawhichemit occu BOILER-COMP(31 IF OR 100,000 BTU) ISSUANCE DATE hmardous air contaminants as defined by the Bay Area Air Quality Maragement Gomel? BOILER-COMP(OVIi0.1WW,UBTU) ❑Yu ❑No NEW RFSIDENTLAL MECH. SQ.IT. p�k I have mad the hoommus materials requirementsr under Chapter 6.95 of the "` B D California Health&Solely Code,Sections 25505,25533 and 25534. 1 understand that if the building does not currently have a mount,that it is my responsibility to notify the Nov 23 ocupant or the requiremenU which must be met prim 0 ismantt of a Certificate of 19 u ccupancy. //svII OwncrarnuNorieadagcnt DolAe ISJ(11IDYBYJI s,J OFFICE