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26568APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING - KLEG IHICAL BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL BUILDING PROJECT IDENTIFICATION PERMITNO. 26568 BUILDING ADDRESS:SANITARYNO. �J o � s? 011�J (���� �� Tr' .'$UNITM OTM APPLICATIONSUBMITTALDATE G� OWNERS NAME: ONE,: CONTRACTOR'S NAMEV:,I LIC NO: I ` N/C ❑ CONTROL# ARCHITECT/ENGINEER: LIC NO: ADDRESS:��N A� PA' T RID ' // W IFEE CONTACT: CqHOn I QTY, ELECTRIC PERMIT PEE BUILDING PERMIT INTO BLDG ELECT PI,U,y1B MECH JNB[T/I 'ryd/t K�Tj t/� �5 1 I �/ f' Cl,y+ll`�i QU.I�/�� S D %2/ PERMIt'ISSUANCF. LICENSED CONTRACTOR'S DECLARATION I hereby affirm that Don licensed wader t rovisiom olCh.pim, 9 (commenoitg with APPLIANCES - RESIDENTIAL JOB DESCRIPTION Section11me7000) andof DivisionJrf the Business and Professions Cole, and my license is in run mree anderne 52A L►S License Cl Lic.#- PANELS UP T0200 AMPS �� � Dare Contractor I 1 10 CFIITECTS DECLARATION 1 understand my plans eM1sll be used as public records.© 201 - IIXq AMPS OVER 1000 SQ. FT. FLOOR AREA QrJ E/SQ. FT. SIGNS LCfRICAL License) Professional OWNER -BUILDER DECLARATION I hereby affirm that 1 am exempt from the Conduclot's License Low for the )JpI"CIALNkUJITMISCJ.y /(21i h\ (4 1, TEMP. M P ST. fallowing reason. (Section 7031.5, Buss sineand Professions Code: Any city or county IW which rel raw, a permit to pectoral, alter, improve, demolish, or repair any svudure prior to its issuance, also requires the appl imnt for such Feted t to file a signed stateme POW ES% , that he is license) pursuant m the provisions of [he Contractors License law (Ch ter 9(commencing with Sallon'ID)(n of Division 3 ofthe Business and Professions e) SWI I TRIC VALUATION or that he is exempt therefrom and the busis for the alleged exemption. Any virlati permit subjects Section 9031.5 by any applicant for a pesubjects lheappllcont m d a vll penal of l 7�' �1 ✓✓✓ TTI O L S- WI S- / TURES m not ore than five hundred dollars (SSOB). ❑ I, as ownerortheproparty,ermyemployee with wagesastheirsole n, competent RESID LLL ([IR _SQ. FT. STORIES TYPE CONSTRUCTION R( will do thewmk, and the svuaure is not intendedoroffered forsale(Sea.]04,1"asin s and Professions Code: the Comrracmis License Law does not apply to an owner o VJ . propenywhobuildsorimWovesthereon,andwhodoessuchwmkhimsclforthroughhis employees provitledthat stchimprovememearcnotimendedorrfferedforeele. If, OCC GROUP RES. UNITS TOTAU 047. owev her, the building rrimprovement is®Id withinrteyearrfcompletinn, the owner- builder will have the burden of proving that he did not build or improve for purpose of sale.). ❑ I,usowneroDhe properly.omexclusivcly convazting wird licensed contracmmw QTY. PLUMBING PERMIT FEE FLOOD ZONE APN construct the project (Sea. 9044, Business and Professions Code:) The Contractor's License Law doe not apply to anownerof property who builds or improves thereon,and pgRMIT ISSUANCL ^ ev whoeootmds forsuch projects with aeoovocmr(s) licensed putamat to the Contractor's se Low. License ALTEk- GRAIN&VENT - WATER (EA) FEE SUMMARY ❑ l um exempt under Sec. B & P C for this reason BACK FLOW PROTECT. DEV ICE OUTSIDE FEES SANITARY Y N RECEIPT# Owner Date DRAINS - FLOORROOF, COND. . . WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N ❑ I hereby affirm that l have a certificate of consent to self -insure, or a certificate of Workers'Compervandea Insurance or a eenified copy thereof(See. 3903, Lab C.) which covers all employee's under this permit. Policy # RECEIPT# FIXTURES - PER TRAP PARK HE Y N RECEIPT p GAS - EA. SYSTEM -1 INC. 4 OUTLETS BUILDING DIVISION PEES Company GAS - EA. SYSTEM -OVER 4 (EA) PLANCHECK FEE ❑ Certified copy is hereby famished. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE BIZ - ❑ Certified copy is filed with the city inspection divisiov. CERTIFICATE OFEXEMPTION MOM WORKERS' GREASETRAP SOILS FEE COMPENSATION INSURANCE SEWER -SANITARY -STORM EA. 20al ENERGY FEE (This section need nm he completed lithe permit is foronehundred dollars (3100) or less.) WATER HEATER W/VENT/ELECTR PAID I acidly that in the Performance ofthe work for which this permit is issued,) shall act employ any person in any manner so as to become subject to the Workers WATER SYSTEMITREATING Date Receipt# Compensation Laws of Califomia. Date Applicant NOTICE TO APPLICANT: If,after makingthis Cenificateef Exemption, you should NEW RESIDENTIAL PLMJL SQ. FT. TOTAL: Become subject to the Workers Compensation provisions of the Lubor Code, you most forthwith comply with such provisions or this permit shall be deemed revoked. 2 I0S•.7 BUILDING FEE SEISMIC FEE V CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.) TOTAL: 1157 3 ELECTRIC FEE Leader's Name1 QTY. MECHANICAL PERMIT FEE PLUMBING FEE 3 Lenders Address I certify that I have read this application and slate that the above information is I egremo comply with ill city unJ county ordinances and smte laws relating m - PERMIT ISSUANCE MECHANICAL FEEerect. building construction, and hereby authorize representatives of this city m enterupon the above-mentioned property for inspection pinfu . ALTER OR ADD TO MECH, CONSTRUCTION TAX (We) agree to save, indemnify and keep harmless the City of Cupertino against Iiabilities,judgmems, consaadexpenses which may in any way accrue against said City AIR HANDLING UNIT (TO 10,1100 CFM) ince cncoq[the grouting o this permit. AIR HANDLING UNIT (OVER I0,000 CFM) EXHAUSTHOOD(W/DUCq PAID Signature of Applican Com ct r I� HEATING UNIT(TO 100,000 BTU) HAZARDOUS MATERIALS DISCLOSURE Date Raeipt# HEATING UNIT (OVER 100,1100 BTU) TOTAL: Will the applicant or future building rampant store or handle hmardous material as dented by the Cupertino Municipal Code, Chapter 9.12, and the Health cad Safety VENTILATION PAN (SINGLE RISID) Code, Section 25532(a)9 El Yes ❑ No ISSUANCE DATE - Will the upplicaotorfambe buildingoccupanruse equipmenlordevices whichemit BOILER- COMP UMP OR IW," BTU) BOILER - COMP(OVER UJIL"BTU) hazardous air coulsminants as defined by the Bay Arca Air Quality Management District! ❑ Yes ❑ NoC 1 2 �I1(�9JJ OCT E -" `Y NEW RESIDENTIAL MECH. SQ. FT. 1 have read the hazardous materials requirements under Chapter 6.95 of the Calif ncia Health & Safety Code, Sections 25595, 25533 and 25534. I undersand thatICA CITY ur kiur= I mu /t 3 if he building Jces not cummly have a tenant, that it is my responsibility to notify the - - - occopent of the requirements which most be met prior to issuance of a Certificate of Occupancy. ISSUED BY: Owner or amhotized agent One TOTAL: 3 OFFICE