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25204 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO I .L r A PERMITNO BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 25204 5ZOT BUILDING PROJECT]DENTIFICATIDN BUILDINNG�ADDRESS: SANITARY NO. APPLICATION SUBMIITALDATE UNITM LOTS (; <A OWNF: NAME: PHONE: CO \S ME: NIC CONTROLM RC111TFiCT/ENGI LIC NO: ADD RESS: I- r I Jj ,re El 'ONTAC'E PHONE: QTY. ELECTRIC PERdT FEE BUILDING PERMIT INFO If ELECT PLUMB MECH PERMIT ISSUANCE ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL 3p W ! / Qwz I hereby affirm that l am licensed under provisionsofaripter9(commencing with VA00 Section7M)of Division 3 of the Business and Professions Code,end my licerue is in PANELS t to 11 force and off 1 . <Zµ Li Lic.0 UPT02MAMPS rtes« em Contractor 201-1000 AMPS Z FO vNi ARCHITECTS DECLARATION OVER I"AMPS SQ.PT.FLOOR AREA E/BQ,PT. 0 Z-'� I understand my plans shall he used as public records. N W SIGNS ELECTRICAL < Licensed Pmfession l 04 9ce< OWNER-BUILDER DECLARATION SPECIAL CIRCUCDMISC. �OyF I hereby affirm that 1 am exempt from the Comactods License Law for the W 3 W to following realm.(Section 7031.5,Business and Profusiuv Cade:My ciy m county TEMP.METER OR POLE INST. X 01 which requires a petmirto construct,aper,improve.demolish,Or repair any strucmm � '2prior to its issuance,also requires the applicantforsuchpermitmfit.signcdmadratnt POWER DEVICES 0 owl<0that he is licensed pursuant to the provisions of the Communes License Law(Chapter o.Lk9o� 9(commencing with Soetion]000)of Division 3 of to,Business and Professions Cade) SWIMMING POOL ELECTRIC VALU Www or that he is exempt herefrom and the basis for Ne alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES �60� Za Section 7031.5 by my applicant for a Permit subjects theapplicanno a civil penury of 0 not mote than five hundred dollars($501p. NEW RESIDENTIALELECTR _SQ.Up. ❑ Lmown rivehuproddollarmyemployaswithwegesntheiraolecampcnmfion, STORIES TYPF.CONSTRUCI'ION a� will clothe work,and the structure isnot intended oroffertd fmraale(Sm.]044,Business and Professions Code:The Contractor's License Law names not apply to an owner of propenywhobuildsm improves thereon,and whmdoessuchworkhimxlforthroughhis OCC.GROUP RES.UNITS ownemployms,WmidMt atsuchimprovemmtsmetwtimendMwoffetndfmsele.IL however,the buildingaimprovereeat is sold withinone year ofcompletion,themwner- TOTAL: builder will have the burden of proving that he did not build or improve for purpose of sale.). . PLUMBING PERM�,T ❑ I,nowner oftheproarty,amexdusively conuazting wiN licenxd]contrnemrs to QTYFEE FLOOD ZONE APN mosses the project(Sec.]094,Business and Profeuron Cada)The Comrecwr's License Lawdasnnt apply loanownerofpres ropeny who builds mimprovestherson,and PERMIT ISSUANCE, E © I a V A' whocontmctsfarsuch projects with aconwemr(s)licensed pursuant mthe Commnor's License Law. ALTER-DRAIN&VENT-WATER( \ F\/1 0 1 0 —r F- Ey SU MARY ❑ 1 am exempt under Sm. ,B&P C for this rearms BACK FLOW PROTECT.DEVICE. ' u v T Y N Owner Data RE UPT4 WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,� OND. DA E Y N ❑ Thereby affirm that l have u enifcate ofcmxm to self-insure,m a ccnifcae of FIXTURES-PER TRAP EIPTN Workers'Compensation lnsumnceora married]copy thereof(Sec.3800,Lab C.)which PARK FEE Y N covers all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPI'M Policy g BUILDING DIVISION FEES Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE ❑ Codified copy is hereby famished. ❑ Certified copy is fled with Ne city impecfon division GREASEANDUSTRL WASTE INTERCEPTOR GRADING ME CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEF. COMPENSATION INSURANCE (This section need not be completed ifthe permit is for one hundred dollars P$100) SEWER-SANITARY-STORM EA.2001"1'. ENERGY FEE or less.) I certify that in Me performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR not employ my Personn any manner so as to became subject to the Workers' PAID Compenmtionl.awsof CaOfomia Data WATER SYSMMITREATING Dam Romilsa Applicant rZZ NOTICE TO APPLICANT:IL after making NU Condcam of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL: r becomesubjeetolhe Worker's Compensation provisions of the Labor Cade,you must r>-v forthwith comply with such provisions ar This permit shall be deemed invoked. BUILDING EEE LSI QO CONSTRUCTION LENDING AGENCY SEISMIC FEE U z Irk for affirm Nm there is asued(Sm.3lending agency for the performance of TOTAL: ELECTRIC FEE O the work for which this permit is issued(Sec.309],Civ.C.) �+ Lender's Name O I-+ QT,Y. MECHANICAL PERMIT FEE PLUMBING FEE Lenders Address LUI orally that 1 have read this application and stale that the above information is MECHANICAL.FEE cnrmct.lagrtemcomply with ell rity mM cowrymNinancn end nam laws rtla0ng to PERMIT ISSUANCE buildingcomtmction,and hereby authorise rep rsenmtives o(this city reenter upon the CONSTRUCTION TAX V Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. (We)agree to save,indemnify odd keep harmless the City of Cupertino against liabilitin,judgments,casts and expenses which may in my way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM) in consequence of the granting of in it AIR HANDLING UNIT(OVER 10,0110 CFM) Signature of ApplicanUConuacmr 'OeDam EXHAUST HOOD(W/DUCT) PAID \ HAZARDOUS MATERIALS DISCLOSURE MATING UNIT(TO 100,"BTU) Dam RVAPM Willtbe applicant or future building cocupma mre or handle heardom material HEATING UNIT(OVER 100,000 BTU) OT m defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety Code,Section 2553E(a)? VENTILATION FAN(SINGLE.RESID) 11 Yea ❑No Will the epplicantmfuwrebuildingacupantux equipment mdeviaswhich emir BOILER-COME DHE OR 100,000 BTU) ISSUANCED TE amadous it commitment us defined by the Bay Arte Air Quality Manegeme. BOILER-COME(OVER 100,000 BTU) inrio? 11 Yea 12tW a ' D YNo NEW RESIDENTIAL MECH. SQ.1"f. Y I have and the havafdous materials requircmeur,under Chapter 6,95 of the ��� California Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the building does Out currently have a tenant,that it is my responsibility to notify the occupml of the reyuixments which must be,met prior w dif issuance of a Cecam of Occupancy. I I f1111VV Owner or umhmdud agent Dam TOTAL: ISSUED BY: OFFICE: