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25062 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 411117.�/ENGINEHR: UPERTINO -- ^ PERMIT NO. DIVISION APPLICATION/PERMIT PING PROD - T MECHANICAL 25062 BUILDING PRIJJF.LT IUN.NI'IFICA2'ION ESS SANITARY NO. APPLICATION SUBMITTALDATE NUNIT# LOT# ��1�: PHONE: C TRACTOR'S NAME: LIC NO: N/C CONTROL# CoBe)01NEliR: OC LIC NO: 620 ADDR $` , w , ❑- PHONE: �V BUILDING PERMIT INFO QTY, ELECTRIC PERMIT FEE BLDG ELECT PLUMB MECH Lii-al� 9 pi„1LJ PERMITISSUANCE .t .V ❑ ❑ El ❑ LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDE 1. QWz I herebyaffirm tat l am licensed underpmvisionsofaspter9(commencing with JOB DESCRIPTION ts100 Section]fl(1117 Of Division3of the Business end Professions Cade,rod my license is in PANELS S;W fill.end effort. � Fz Date Com UP T0200A Dam Conwmorrs, -I S SQ.FT.FLOOR AREA $/SQ.FT. ZOZ=X, ARCHITECTS DECLARATION ER AMP I I understand my plans shall Ne used as public records. / SI ELECT I © I F� Licensed ProressmmI W OWNER-BUILDER DECLARATION SPECIAL CIS SC. �OaU I hereby affirm that 1 an exempt from the Convector's License law formic j W:I:a following mason.(Section 7031.5,Business and Pmfessions Code:Any city or county TEMP.METE POLE ST, j 1 m J which requires a permit tO custom,alum,improve,demolish,Or rep or any stmc,urc POWER DEV I ( �1 fir[ }� prim min issuance,alamrtquirea the applicant for such pemmino fileesigned satamem T �-J ppm that he is licensed p.rsuam to the provisions of the Conrwtors License Law(Chapter SWIMMING PO ELECTRIC VALU N O Q a�'eLL 9(conunrncing with Section]gp)Of Diviaion3of the Business and Pmfessions Code) mica.he is eaamp,therefrom it Ne basis(o th.alleged exemption.An,vinlm.rim' pUTLETS-SWITCHES-FIXTURES QSermon 0031.Sby any applicant for a permit subjects the applicant u a civil penalty of not morcthan five ny.Lddollua($500). . K Q ❑ I,as Ownrofthep M.ormyemployceswithwagesavheirwlecomp madon, NEW RESIDENTIAL ELECfR S QPI'. STORIES TYPF.CONSTRUCION y will dnthewons andthe he Cecisnb's License not apply 0044,Business end Professions Code:The Comrecurs License Lew does not apply tow owner of property w dsorimpmvea hereon,andwnessuchwmk himselfu throughhis employeas,,provided thin such improvement,mrent intended Or offered for role.If, OCC.GROUP RES.UNITS however.In,building urden of proem Tshild within one yem ofi mproetlf r the purpose of a3 p builder will have the border of proving Chet he did not build Or improve for purpose of TOTAL: s IcJ, ❑ I.uownerofthepmpeny,amexclusivelyconvactingwiNlicenaedc.n.am.rsm QTY. PLUMBING PERMIT FEE FIAODZONE APN comtmn the project(Sec.70414,Business end Professions Coded The Contracture PERMIT ISSUANCE License Law dues not apply to an ownerafpropeny whobuildaoriilaomathemorr and whocomrects fimsuch projeca with acantracmts)licensed inummiumhe Contractor's License Law. ALTER-GRAIN&VGNT-WATER(FA) FEE SUMMARY ❑ I am exempt under Sec. ,B&PC for this reason HACK FLOW PROTECT.DEVICE O E FM SANITARY YN Own, Data DRAINS-FLOORROOFAREA, RECEIPT# , , , . WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN ❑ Thereby affirm mmlhaveecenificam of consentmulf-insure.macenificammf FIXTURES-PER TRAP RECE!"Is Wmkaf Companauos lnsureaceora ccnified copy memof(Sec.380),Lab CJ which I PARK FEE Y N cove (�f�p1y �}1 GAS-EA.SYSTEM-1 INC.4OUTLETS RDIVISI N Policy NI x^+L-Atu� y �'"o/a4 BUILDING DIVISION FEES 0 CvdT-cpmhe 1yf�5 GAS-PA.SYSTEM-OVER PLANCHECK FEF. ❑���...111 CenifieA copy is hereby famished. - �$ Cci ified c.py is fried with thecity inspection division. GREASEfINDUSTRL WASTE INTERCEPTOR GRADING FEE - CERTIFICATE OF EXEMPOON FROM WORKERS' GREASETRAP SOILS FEE COMPENSATION INSURANCE (This section need not becompleted ifine permit is foronehundmd dollars($100) SEWER-SANITARY-STORM EA.203FT. ENERGY FEE or less.) I cattily but in the pertormance of the work ROr which this permit is issued,l shall WATER HEATER W/VENT/ELECTR not employ any person in any manner so as to become subject to me Workers' PAID z Compensation Lawsof Califomia. Data WATER SYSTEMITREATING Data Receipt Applicant 0 NOTICE TO APPLICANT.If,after making this Cenificam of Exemption.you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL: s U) become subject 1.am Workers Compensation Provisions Of the labor Code,you must forthwith comply with such provisions Or this pernitshal l he deemed Owm ed. BUILDING FEE W �-r Q CONSTRUCTION LENDING AGENCY SEISMIC FEF. 1 heresy affirm that them is i construction lending agency for the pertmmence of s So L) O the work for whi s Q�'�k issued(Sen 3097,Civ,CJ TOTAL: � ELECTRIC FF.E Leadera Name ��a-+e'a PLUMBING FEE OF Lenders Address - QTY. ` MECHANICAL PERMIT FEE L) 1 certify that I have read this application and state that the above information is GSI gree comply city Y 8 -� MECHANICAL FEE O mrtcn.Ia to I with all ci and ordinances and xteu laws mletin m PERMIT ISSUANCE ybuilding conmructi.n,and herchy authorim reprtwmativea of this citymcnumup.0 the CONSTRUCTIONTAX Z above-mentioned pmpeny for inspection purposes. ALTER OR ADD TO MECH. Z (We)agree to save,indemnify and keep haredeas the City of Cupertino against linbilities,judgments,c,stspp@ndexpmuawhich may in any wayaccrue againstsaid City AIR HANDLING UNIT(TO 10,0110 CFM) in cn entt opthe ren/rte mm amtit. u / I MR HANDLING UNIT(OVER IO.t100 CFM) Signature of App/hcan IC rucm, to EXHAUSTHOOD(W/DUCT) PAID HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO Hat"BM) Date Receipt Is Will theapplicdu or future building occupant atom.,handle haaentim,material HPATING UNIT IW,WO BTIII TOTAL: as defined by the Cupenin.Municipal Cade,Chapter 9.12,and me Health and Safety py Code,Section 255324)? VENTILATION FAN(SINGLE RFSID) O J ❑`Yes <NO ISSUANCE DATE Willtheapplicantorfuumbuildingmeupantuuequipmenmrdevicnwhichemit BOILER-COMP(3HPOR 100.000 BTU) haaard.us air contaminants m defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 1010,000 BTU) P A I D District? 13tta,,JJJ Yas J[J No NEW RESIDENTIAL MECH. SQ.FT. I have read the h'cesrdd..ua materials tequirtmena under Chapter 6.95.f the MAY 111993 Califomia Healm&Safety Code,Sections 25505,25533 and 25534. 1 undersand that if the building dues not currently have a must.that it is my responsibility m notify the '0'�) Ur wrCn(11VU occ.pe o�f�the�m is which must be ma prior a issuwee of a Certificate of -( V16;n, 1nVC Ownemomaummrsda , Date TOTAL -Q ISSUED BY: '