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27670 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES USE BALL POINT PEN ONLY CITY OFCUPERTINOBUILDING-ELECTRICAr PERMIT NO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL v /N O BUILDING PROJECT IDENTIFICATION L BOILDIN(G�A'D�D'RJESS://�/� - ' ILS• (�L�PhJf.ir'fdG_ G SANITARY NO. APPLICATION/SUBMITTAL DATE �- UNITq LOTM 1 WN RS NAM PHONE: CO CTOR'S E: LIC NO: L TV`a�+y N/C CON IROLI CHI'rECT/EIJOINEER: LIC NO:, ADDR S ❑ Ca ACT: PHONE:, J /,f)/!,,I? QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO J _vVpPERMIT ISSUANCE BLDG ELECT PLU B MECH ' • El 0 13 LICE S D CONTRACTOR'S DECLARATION pyZ I hereby affirm that l am licensed under APPLIANCES-REBIDENTIAL JOB DESCR] ION IFi1 bit Professions Coe,and (commencing with 00F Sxtion]Oo0)of Division]pf the Business end Professions Code,and mylicense is in PANELS O tit W full force and effect. ¢Z License Class Lic.It UPT02MAMPS sO''y Date Contractor 201-1000 AMPS Z FO w 7J- ARCUITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA 1;/SQ.FT. Oy Z_G 1 uodersEnd my plans shall be used as public rectum. F^NJSIGNS ELECTRICAL - ucenaoa Profeaamnal that NERI.,x In fir DECLARATION SPECIAL CIRCUIT/MISC. ip0.a5�,O d F 1 hereby affirm that 131 exempt from the Contractor's ons Co e:Any Lew battles W 3 m following reason.(Section]03 L5, In end Professions Code:Any city or county TEMP.METER OR POLE INST. yt::lil which requires a permit m construct,aher,improve,demolish,or repair any structure. CQ� priortous issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES ' pl Q p that he is licensed pursuant to the provisions clubs Contractor's License Law(Chapter Mo�' 9(commencing with Section 7000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION Mae or that he is exempt therefrom and the basis alleged exemption.Any vipletionof G See 703 LS by any applicant fora permit subjects the epplicantmacivilpenaltyof OUTLETS-SWITCHES-FIXTURES , not mare than flue hundred dollars(5500). ❑ I,ssownerofthe NEW RESIDENTIALELEC'TR _SQ.PT. propeny,ormyemendeeswiNwed fier Nei(Sec. 0*4,Business STORIES TYPE CONSTRUCTION L 22 will doth work,and the swemreisnors Liceese La do es not apply to Business and Professions Code:The Contractors License Lew does not apply lf an owner of prppeny who builds orimpraves thereon,and whodcee each warkhimxlfarthroughhis own employees provided thatsuchimprovemen[s arcnptimm�ded proffered Forsale.If, OCC.GROUP RES.UNITS however,the building or improvement is sold within one year of completion,the owner- builder will have the burden of proving that he did not build or improve for purpose of TOTAL: sale.): ❑ I,asownerofthepmo ny,amexclusivelyeonoactingwiNliceased contractors to QTY. PLUMBING PERMIT FEE EFLOOD ZONE APN construct the project(Sec.9044,Business and Professimrs Code:)The Contractor's License Law does not apply toanownerofpropony whobuildsorimproves thereon,and PERMIT ISSUANCE who ponmacts foramen projects with acommctons)lieensedpurs annothe Cpmmetor's' License Law. u .. ALTER-DRAIN&VENT-M'- ELANCHECK FEE SUMMARY ❑ I am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DOUTSIDE �ES Owner ANITARY Y N Date DRAINS-FLOOR,ROOF, RECEIPTM WORKMAN COMPENSATION DECLARATION CHOOL TAX YN ❑ I hereby affirm that l have a cenifluto ofconsenno self-insure,Ora certificate of FIXTURES-PER TRAP - RECEIPTM Werkers'Compensationder this at acertifed copy thereof(Sec.3800,Lab CJ whichARK FEE Y N covers all employee's ander Nis pectate GAS-EA.SYSTEM-1 INC. RECEIPTk Comp p BUILDING DIVISION FEES Company GAS-PA.SYSTEM-OVER "❑ Certified copy is hereby famished. - FEE ❑ Certified copy is riled with the city inspection division. GREASEONDUSTRL WASTE INTERCEPTOR GRADING FEE CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS ME INSURANCE - (This sermon need not be completed ifthe permit is porous hundred dollors($100) or less.) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE I cenify that in the performance of the work for which this permit is issued.I shall WATER HEATER W/VENT/ELECTR not employ any person in any manner so e to become subject to the Workers' PAID Z Compensation Laws of California, Date WATER SYSTENOTREATING Data Receipt It O Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL FILMS. SQ,FT. TOTAL: [� 9) hecome subject to the Worker's Compensation provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE LkI Q CONSTRUCTION LENDING AGENCY SEISMIC FEE z I hereby affirm that there is a construction lending agency for the performance of V0 the work for which this permit is issued(Sec.3097,Civ.C.) ELECTRIC FEE (A Lender's Nome Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE - WI certify that 1 have read this application and state that he above information is correct.l agree to comply with all city and county ordinances and state laws relating to PERMITISSUANCE MECHANICAL FEE �' building construction,and hereby authorizemprsenmtives ofthiscity to enteruponthe C) 7 above-mentioned propeny for inspection purposes. ALTER OR ADD TO MECIL CONSTRUCTIONTAX F7 (We)agree to save,indemnif d keep lis mless the City of CLpenino against liabilities,] nts,contsan pe ichmay in any way acmueagainst said City AIR HANDLING UNIT(TO 10, CFM) cons f the gm g o rs s it. AIR HANDLING UNIT(OVE Io,000CFM) gnatme of Applicank4soffilfgror J-- Date EXHAUST HOOD(W/DU PAID HAZARDOUS MATERIALS DISCLOSURE BRAYING UNIT(TOl ,000 BTU) Date Receipt It Will the the Coaertion urebuildi Carlo, pentsmre2,had the Health and Salty HEATINGUNIT O RIOO,WOBTU C defined by the Cupertino Municipal Code,Chapter 9.12,and the Health end Safety ( ) TOTA 6L Code,9wii Y5532(a)P 11 12 No VENTILATION N(SINGLE RE ) Will air co trantnrfuwre building by the use Area Aen Quality reswhichemit BOILER-C P(3HPOR 100,000 B ISSUANC DATE Yxamvr us air comaminents as defined by the Bay Area Air Quality Management DlsMcty BOIL -COMP(OVER 100, ) I ❑Yes ❑No NEW ESIDENTLM. SQ. pppp 1 have read the hazardous materiels requirements under Chapter 6.95 Of the LM California Health&Safety Cede,Sections 25505,25533 and 25534. I understand that if the building does not currently hove a tenant,that it is my responsibility to notify the - s J A �� cupant of the requirements which must be met prim to issuance of a Certificate of "•b1 C Occupancy. , s/ Owner or authorized agent Date TOT L: ISSUEDB . OFFICE