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25769 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINOi ..IL. �ELECIRJCAL PERMIT NO. APPLICATION/PERMIT PLUMtlING-MECHANICAL. C J BUILDING DIVISION BUILDING PROJECT IDENTIFICATION J r BUILDING ADDRESS: SANITARY NO. APPLICA9'IONSUBMITIIAALDATI 1143 1 ��Y UNIT. LOT# I �`��S OWN 5 A ♦ eLg IPJ a CONTR R'SNAME: LICNO: `��! �i� K ` M N-` N/C CONTROL# • ARCIII'I'ECE iNGINEER: •J LIC NO: A ESS: ff r I✓ 1 CONTACT: PHONE: QTY. ELECTRIC PERMIT F4, BUILDING PERMIT INFO Nd.DCi ELECT PLUMB MItCH PERMIT ISSUANCE 1L�/L} ❑ ❑ ❑ LICE,Ireen CONTRACTOR'$DECLARATION APPLIANCES-RESIDENTIAL QyZ Ih7050dofirmthat3 amlice Buiro ,and isionsa ns Code, and mmecense with LOB DESCRIPTION uF10[u0[=. Semiofall rceand)of Division 3nf the Business and Rofessions Code,and my license is in PANELS aUU License ClinJcf[ea. UPT02WAMPS �g•L�/'�#/.(�1.`_' FZy1 License Claes Li,q ,<0- Date Contractor 201-1000 AMPS 5 FT.FLOOR AREA $/SQ.FT. ZO,— ARCHITECTS DECLARATION Q OVER 1000 AMPS OZ-0 I understand my plans shall be used as public records. P y F; SIGNS ELECTRICAL eat. Liccnxul Professional 6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. kC W U 1 hereby affirm that 1 nm exempt from the Contractor's License law for the m 3 a y following reason.(Sectors 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST. F < which requires a permit to cones.,alar,improve,demolish,or repair any stmemm ern>� prior to its issuance,also res its the applicant for such permit o file.signeddidement POWER DEVICES �K<O that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter arc9(commencin44 g with Seaton 7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALU IW W=rm orthat he is exempttherefrom and the basis for the alleged exemption.Any violation of F- OUTLETS-SWITCHES-FlXTURES ©�/� Z Q an Section 7031.5 by y applicant far a permit subjxts the applicant m a civil pxmlty of 21- not more than five hundred dollars($5W), NEWRESIDENTIALELECIR SQ.FT. K p C3I,asawneroflhepr..pony,maryemm ployecewithwagesasthei...lecopensdaric SIORIES TYPE CONSTRUCTION a6— will do the work.andthe structure is not intended proffered l'ormle(Sec.7044.Business and Professions Code the Contractors License Law does not apply to an owner of pmpenywM1ilooddsofimprs.thereoganJ whodxssuchwmrk himulfa,through his m vJ L� cmployas.providedilat... impmvementsarenmtimcndedoro(Pored foraale.If. J C. R U RES.UNITS M1mwevcq dee building orimprovemem is old within oney<ar of completion,thanwner- TOT L vt n p Q builder will have the burden of proving that he did not build or improve for purpose of I� sole.). QTY. PLUMBING PERMIT FE /� NE APN ❑ Las ownerofthe pmpenY•amexclusivdy cmntmning wide licemedcontrxtorsto ommum the pmjxt(Sec.7044,Business and Professions Code)The Contractor's Licenu law dmesnmapply to an mwnermfproperty whobuilds mrimpmves Hereon,and PERMITISSUANCE who contracts forsuch pmlccts with aconuaaor(s)Iicensedpursuantmthc Convactmes ALTER-DRAIN&VENT-WATER License Law. (FAO FEESUMMARY ❑ I am exempt under Sec. ,B A PC for this reason BACK MOW PROTECT.DEVICE OUTSIDE FEES SANITARY Y N Owner Date DRAINS-Fl.00R,ROOF,ARFA.COND. RECEIPT# • cove WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N ❑ er,'Cayaffimrthatlhootive nifiwuof conummu(Sex,38M.Led, C.)hick FlXTURES PER TRAP RECEIPTp Workcr,2 Cnmpensalimn lnwrance nr aneniEN copy lhered(Sx.38W.l.ab C.)wbich PARK FEE Y N rs all employee's undcnhis permit. GAS-EA.SYSTEM-1 INC.4 0UTLETS RECEIVP# Policy# I BUILDING DIVISION FEES ❑Co.CcnifiW copy ishcreby famished. GAS-EA.SYSTEM-OVER4 TEA) PLANCHECK FEE ❑ Ceniliedcopy)s filed with dee city inspection division. GREASFnNDUSTRL WASTE INTERCEPTOR GRADING HE TIFICATR OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE COMPENSATION INSURANCE (This cacti need not becompleted ifdee permit is frronehundresi dollars(SIM) SEWER-SANITARY-STORM FA.20OP'T. ENERGY FEE or less) I certify a tinthepeformanceoftheworIt for which thispcnnit is issucd,I shall WATER HEATER W/VENOELECIR no iploy n n y m�Pncr so as to bacon subject m the Workers' PAID en II o lif nQ Data , WATER SYSTEMMEATING Date Receipt ex Q z Applicant Z ZVNOTICET APP ANT:I(,a ter ma ing Nis Cen fi am of Excmp mn.ynu should NEWRESIDENfIALPLMH. SOFT. TOTAL: ybecomesubjectile Workers Compensation provlsimnsmfthehabor Code.you must aforthwith comply wide such provisions or this permit shall he deemed revoked. BUILDING HE OW. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE z I hereby all that there is a construction lending agency for dee Performance of U O dee work for which this permit is issued(Sax.3097,Civ.C.) TOTAL: ELECTRIC FEE Lender's Name O U Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE I certify that 1 have read this application end state that the above information is correct. l some to comply with all city and county ordinances and state laws meaning in PERMIT ISSUANCE MECHANICAL FEE 1--' 0, building construction,and hereby authorim upmsentatives of Nis city mernnuponthe CONSTRUCTION TAX U Z abovcmcntionM property for inspection purpmses. ALTER OR ADD TO MECH. (We)agree m sov der-ify and keep harmless dee City of Cupertino against liabilities,' encs sts and expe cs which may in any way ace eagamd aid City AIR HANDLING UN TIT 0111,000 CFM) in co gran ms permit. AIR HANDLING UNIT(OVER 10.000 CFM) Signature of AMlicant/Comonfor Dote EXHAUST HOOD(W/DUCD PAID I IAZARDOUS MA'I'BRIMS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dole Receipt# Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER IW.WO BTU) )T as defined by the Cupertino Municipal Cod,Chapter 9.12,said Ne Health and Safety Code,Section 25532(a)? VENTILATION FAN(SINGLE RESID) El yes ❑No Will thea licamnrlbture buddin BOILER-COMP(311P OR 100,W0 BTU) ISSUANCE ATE pp grby he Bare Am.Air Quality Management P bazarJmm air contaminants as define)by the Bay Ara Air Qualiry Munagemem BOILER�COMP(OVER 100.000 BTU) � Q District? /1 ❑Yes ❑No NEW RESIDENTIAL MECtI. SQ.FT. yT/0 [# 1 have read the hazmduas materials requiremems under Chapter 695 of dem ,V �.7 p if theb wilding does &Safety ur Cntly have aena5505at it is y responsind 25534.bility (understand dear if the building docs not m currently w have a tenant,that n is my responsibility a notify dee 9 occupant of the requirements which run be tun prior to issuance of a Certificate of Lt,r Occupancy. Owner or amhoriud agent Date TOTAL: ISSUED BY: OFFICE