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24965 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO - BUILDING-KLEU FRICALPERMITNO. APPLICATIONIPERMIT PLUMBING-MECHANICAL A C BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 4 J BUILDING ADDRESS: SANITARY NO. AFMICATIONSUBMTALDATE ' $ Ll" UNIT# LOT# OWNER E: PHONE: CONTRACTOR'S NAME: LIC NO: /i• • �1 ae/hwNIC CONTROL is ARCH! 8Ci/ENGINEER: T•I LIC NO: ADDRESS: ❑ syj CONTACT: PHONE: �' BUILDING PERMIT INFO aa,;iw QTY._¢;, y,ELECTRIC PBRMTI': ' -PEE ��k''E^"" ISSUANCE D ELE PLUMB MECH PERMIT ISSUANCE �' ❑ ❑ LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRI FJ00 !hereby affirmtheliemlicensed undapmvisionenfChapter9(commencingwith r^ �� 00 Section]000)mf Division3 of the Busineae end Professioru Code.end mylicerue is in ppNBL$ 1`' L Pollforce and effect. ' UP TO 200 AMPS y� eC Lie V N Dare Contmcmr OVER Foi-1000 IAMPS F Z HITECT'S DELLA O SQ. .FLOOR AREA $BQ.Ff. 'ZOce— OVER 1000AMPS CZ-0 I unders d m s all be ux as publi orde. ^ ® w , y m�2 SIGNS ELECTRICAL _ E �\`,, 4 .J Licensed essional OWNER-BUIl DER DECLARATION SPECIAL CMCUTDMISC. _ E R OyU I herl,¢from that I em exempt from the Contractor's License law for the 1\ ❑1'3 a y following reason.(Section]031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST. RJ ON; which requires a permit to construct,eller,improve,demolish,or repair any structure prior to its issuance,also requires the applicant for such Permit in file a signed summand POWER DEVICES TE O that he is licensed pursuant to the provisions of the Contractors License Law(Chapter n o 9(commencing with Section]000)of Division]ofNe Business and Prvhasions Code) SWIMMING POOL ELECTRIC VVA/AL�UATI�ya/r WM, or that he is exempt imminent herefroand the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES � _..� ZQ Section]031.5 by any applicant fma permats iuobjthe applicantmecivil penalty of ..77 not more than five hundred dollars($500). NEW RESIDENTIAL ELECTR S .PT. C m ❑ 1,asownerofthepropeny,ormyemployeeswilhwagesmit irsolecompensafim, Q STORIES TYPECONSTRUCTION per, willdo the work,andthe structure isnotimendedoroffamd forsale(Sec.]044,Business and Professions Code:The Contractor's License Lew does not apply in an owner of pmnywhobuildsorimprovesthemm,andwhodms such workhimseifmthrough his OCC.GROUP RES.UNITS own employees,prov ided that such improvements are not intended ar offered for mle.If, however,the buildingor improvement is sold withinone yearofampletion,the owner- builder will have the burden of that he did not build or improve for f TOT proving P PuRos ea ). ❑ 1,asownerofthe'pmpeny,amexclusivelycontractingwilhbcensedcont ci to QTY),+y fa «PLUMBING PERMIT PEE FLOOD ZONE APN SN Licenscarastme the project(Sec.to an Rosiness and Proywhselnns Code)The Contractors License PERMIT ISSUANCE Lice sotrawdeesuc applypjects ithaco mmum(sy whoseditursuar romeCormgand who contracts for each projects with a cool recmr(s)licensed pursoanr m the Contractor a License law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY ❑ I sum exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE - OUTSIDE FEES SANITARY YN Owner Date DRAINS-FLOOR,ROOT,AREA,COND. RECEIPT# WORKMAN COMPENSATION DCCLARATION SCHOOL TAX Y N ❑ I hereby affirm that l have a certifrcam oferament to self-insure,or a certificate ofRECEIPT# Workers m Compensation lnsunceocamped copy Nre eof(Sec.380),Lab C.)which FIXTURES-PER TRAP PARK FEE Y N c.v.all employee's node,this Permit. GAS-EA.SYSTEM-I INC.40UTLETS RECEIPT'# I Policy# BUILDING DIVISION FEES Co ny GAS-EA.SYSTEM-0VER4(G) PLANCHEOK ME enified copy is hereby famished. Certified copy is filed with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE COMPENSATION INSURANCE This section need not has completed if the Permit is for one hundred dollars($1007 SEWER-SANITARY-STORM EA.200FT. ENERGY FEE or less.) I Certify the,in the famfx ce of the work for which this permit is issued,I shall WATER HFBTER W/VENT/ELECTR not employ any person in any insurer so as to become subject to the Workers' PAID Compensation Lawsof Califomia. Date WATER SYSTEM/IREATING Dote Receipt# 0 Applicant Z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL: ,ter T/3 become subject o the Workers Compensation provisions of the Labor Cade,you must t-' ; forthwith comply with such provisions or this permit shall be deemed mvoked. BUILDING FEE � 5 ped, CONSTRUCTION LENDING AGENCY SEISMIC FEE 1 hereby sffimr that there is a construction lending agency for the performance of U O the work for which this permit is issued(Sea.3097,Civ.C.) TOTAL: ELECTRIC FEE �� Lenders Name Ci. (~r k t ° d _ PLUMBING FEE U Lenders Address QTY :? , MCGHANICAL PL•RMIT' FEE, LTI 1 candy Olaf 1 M1evc read Nrs application and stem that the above udormatron i "" r-' " MSCI IANICAL FEE corat.l agree to comply wohallmry county ordinances and stalelaws relating to PERMIT ISSUANCE ybuilding construction,andhercbye ureprcunmtivenof this city upon Ne CONSTRUCTION TAX U z above-menti properly for i tion purynsee. ALTER OR ADD TO MECH. .^� (We) o save,in 'fy and keep harrrde Ne City of Cupertino against liabilities,]dgentacos es maswhich mayi ywey accrue vnstsnid City AIR HANDLING UNIT(TO IB,0OI CFM) in cnnscqu nc ftI gof Ibis pemlit. . 2�5' AIR HANDLING UNIT(OVER 10,000 CPM) ,gnat fApplic Conmeclm Date? EXHAUST HOOD(W/DUCT) PAID HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Dom Receipt# W I the applicant or Troon building paupomt store or handle hazardous material as deo ed by the Cupunina Municipal Code,Chapter 9.12,and the Heahh end Safely HEATING UNIT(OVER 100.000 BTU) TOTAL: CoJ action 255]2(¢)] EI Yee ❑No VENTILATION FAN(SINGLE RESID) ISSUANCE DATE Will heepplicamor fumrcbuildingacupant tiseeyvipmenwrdeviceswhichemit BOILER-COMP(3HPOR IW,IXIO BTU) r I`IWhazardous afr contaminants as defined by the Bay Area Air Quality Management BOILER-COW(OVER 100,000 BTU) PAID *rt] ❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FIE f T have tend the hazardous materiels requiremars under Chapter 6.95 of he APR ,� 1993 California Health&safety Code,sections 25505,25533 and 25534. 1 understand Net lithe building does not currently have a tenant,that it is my responsibility m notify the 6IlY occupant of the requirements which must he met prior to issuance of a Certificate of V y1 Occupancy. - Owner or authorized agent Date TOTAL: ISSUED BY: