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26766 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ME 1'RI nL PERMITNO. APPLICATION/PERMIT PLUMB TIDENTICAL FIC BUILDING DIVISION �`� INILIJINC.PROJECT IDENTIFICATION 26766 BUILDING DDRES \ fZ.SF NITp LOTH SANITARY NO. AI'^P/sL''I'G'f10N2BM99TAL DATE OWN , `w' ` HO[.` CONTRACf(?2%:!%; ,/+n LIC NO: • © `'��JVL_]!`�74aLyT NIC CONTROL# RCIIITECf/ENGINEER: LIC NO: ADDRESS: ❑ CONTAcf: PHONE: BUILDING PERMIT INFO QTY. ELECTRIC PERMIT FEF, BLDG ELECT PLU MECH PERMIT ISSUANCE ❑ LICENSED CONTRACTOR'S DECLARATION APPLIANCES- RESIDENT' L pyz Ihereby a(Rrmthat l are licemaxi under provisionsofCliapler9(commencing with JOB DES IP ION to 00 Section 7000)of Division 3ol'Ihe Busincomd Professions Core,and my license is in PANELS Fly V full force and effect. FZ, License Class Lic.# UP TO 200 AM Dale Contractor. 201-1000 PS ,ZcNZ ARCHITECTS DECLARATION OVER AMPS SQ.FE FLOOR AREA !;/SQ.FT. O Z—M I understand my plus shall be used as public records. t—siiFul NS ELECTRICAL Licensed P..fcx,morl C W� OwNER-BUILDER DECLARATION SPECIAL CIRCU SC. C XOy U 1 hereby affirm.Se that I am exempt from the C,nions Cs License Law for th �u31'-vFGi following rcres a(Section]03Lm r,ainev and Pro,dem re Code:Any city or cu y TEMP.M R LE INST. 'OJ which reyuiresapermit to consumer,alto.,improve,demolish,of repair try sw are POWER UEVI prior to its issuance,also requires the applicant for such permit to file asigr smmto r C pz that he is li<rnsed pursuutto the provisions,(the Convacmrs License Law(Chapte RXCLL 9(commucing with Senion](00)of Division Sof the Boniness and Professions Cade) WIM OLE v C VALUATION W_,� or that he isexcmpl therefrom as the basis for the alleged exemption.Anyviolation of �FZQ Senion]03156y a undredicollars $500). subjects the applicun,..civil penahy of S- -S-Ft RES 'ZD nett hon fisc hundred J,Ilms($SW). CF I,asownvofthe NEW ENTIALE C'Tlt S .PT'. So property,ormyempendedor olwed I orstheir soleeompensadon, Q STORIES 9'YPE CONS'1'RUC'1'ION '3 ems° and work,and the xeCmarsnot intended Live a, apw.]044,Business and Professions Code The Conna<mr s License Lew does not apply m a owner of property whobuild+or improver lhere w1mduessuvh work himself...throm,bhis cmpinyces,providedlhm.wchimpmvementsmenwintendedurofTendforsale.If, OCC.GRGUP RES.UNITS however,the building or improvement is sold within one yearofenmplerion,the owner. 'TOTAL: builder will have the burden of proving that he did not build or improve for purpose of sale.) ❑ Las owncrofthe Property,am exclusively contracting with licensed contractors m QTY, PLUMBING PERMIT FEE PLOODZONE APN onnmct the project(Sec.70,14,Business and Professions Code:)The Convanor's License Lawdess not imllyto an ownerofpropco,whobmid,or improves thereon,andPERMIT ISSUANCE who contracts for such projects with aeorf actorau s)licensed personnel the Contractor's License law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY ❑ 1 am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES SANITARY YN Owner Date DRAINS-FLOOR.ROOF,ARG,COND. RECEIPT# WO hat ANCOMPENSATFONDICLARATION SCHOOLTAX Y N ❑ Ihereb,iffirm thmlhaveacenificme of centore self-insure.m ilecnir"me of FIXTURES-PER TRAP RECEIPT# Wnrkccv'Cmnpensntionlmuruna oreoenlTied copy thereof(See.3800.LbCJwhich PARK FEE Y N coven all employee's under this permit GAS-EA.SYSTEM-1 INC.4 OUTLIiTS RF.CIi1P1'# Policy p Company BUILDING DIVISION FEES ❑ CeniOed copy is hereby famished. GAS-EA.SYSTEM-OVFR4(FA) PGNCHECK FEF, ❑ Candied copy is Filed with the city inspection division. GREASEpNDUSTRL WASTE INTERCEPTOR GRADING TLE CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE COMPENSATION INSURANCE (This uctiunnced nos be em,dened ifthe permit is Forone hundred dollars($100) SEWER-SANITARY-STORM G.2WFT. ENERGY FEE or lens.) I certify that in the performanre of the work for which this TT.permit is Wave,I shall WA � TF.R WNENT'ELECTR not employ try person in any manner so as r, hecnme subject to the Workers PAID Compcnsatiunlawsof Califomia. Date ATERS M/IRRATING z Applicant Date Receipt# z NO TICE TO APPLICANT:TL after making this Certificate of Exemption,you should NEW RESIDENTIAL PL1,1B. SQ.PT. TOTAL. ^F eA becomesubjenmthe Workers Compense«on provisions ofthe Labor Cade,you must � ; fonhwith comply with such pravisions or this permit shall b,deemed revoked. 2 BUILDING FEE UJ Q CONSTRUCTION LENDING AGENCY SEISMIC FEE =) z 1 herchy affirm that them is a construction lending agency for the perfortnuce of U O the work far which this permit is issued(Sec 3097,Civ.C) TOTAL: ELECTRIC FEE Lender's Name 0 U lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE L17 1 certify that I have recd this application and slate that the above information is t•' 6. cornier.I agree to comply with A city and county ordinances and state laws telling1. PERMITISSUANCE MECHANICALFEE UJ but lding construction,and hereby andminre representatives of this ci ty to enter upon the U Z above-mentioned propeny for inspection purposes. ALTERORADDTOMECH. GON$TRDLTIGN TAX (We)agree m save,indemnify and keep hamnless the f penin,li'm, t Iiabililics,judgmcnk,consand expenses which may in any ways ou I AIR HANDLING UNIT(TO 10,000 CFM) in consequence of the grating of this permit. S • AIR HANDLING UNIT(OVER I0110B CFM) 'ig r of pplicun/Cumrecmr Dare BXHAU$THOOD(W/DUCD PAID HAZARDOUS MATERIALSDISCLOSUREHEA TING UNIT(TO 100,000 BTU) Date Receipts Will the u e Cu,ct o fumrc binding de,C at store or name laminations as material asrefined io the 32(a)?no Municipal Code,Chapter 9.12,ad the Health and Safety HEATING UNIT(OVER IW,000 BTU) C�xlc,Section 25532(0T 11 yes C1 No VENTILATION FAN(SINGLE RFSID) Will this comf rntor(uwrc building by the Bay Area Air Qmliv,Mar icM1emit BOILER-COMP(3)1P OR 100.000 BTU) ISSUANCE DATE harmdous air contaminants as defined by the Boy Arca qtr Qualiy Management BOILER 100,000 BTU) Diann] ! JUL. ❑yes ❑No NEW RESIDENTIAL MECH. SQ.FT. N 22 �n/� Lbuildiog read the h-.doses mmerials mquircmems under Chapter 6.95 of the /s/!Y k��f� alth&Safery Cade,Sections 25505,25533 and 25534. 1 understand that - C g Joes nut curcnlly haveamnar.that it is my rcsponsibilitymnotify thehe samiremems which muse le met primm issuance ofa Cenificam ofhnn Td agent Dam TOTAL: ISSUED OFFIC