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26091_ , APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE SALL POINT PEN ONLY CITY OF CUPERTINO msms.DiNG= MAIL TRRIA - APPLICATION/PERMIT PLUMBING -MECHANICAL BUILDING DIVISION BUILDING PROJF.IIT I I ENTIF'ICA'IION PERMIT NO. C 0 (� Q v J1 BUILDIyypylf]D ��� � UNITp� .•��//��\\��''�- LOT p SANITARY NO. APPLICATION SUyB/M��I PTALDA'0? 3�- ILf OWNER PHONE: CO I'RACTQR'S NAME: LIC NO: 1/-JI/GJ- ON IA,,L NIC ❑ CONTROLp CRL II' I?C'/ENGINHER: LIC NO: ADDRESS: .. ONTACT: PHONE: .. QTY. 17LECTRIC PERMIT FEE BUILDING PERMIT INFO L ELECT PLUMB MEC PERMIT ISSUANCE }Y�s�I�V pyr LICHNS CONTRACTOR'S DECLARATION Ilowd,afftem Osatl a licensed under provisionsofChapmr9beourmencingwith APPLIANCES - RESIDENTIAL JOB DESCRIPTION VJ00 y��i1F Section ]000)of Division ofthe Business and Professions Chair. and my license is in Poll Rmmr awd effect. PANELS 6y WVjs) License Class Lic.p UP TO 20IAMPS 201 - 1000 AMPS ' h6 h Uate Common. z Zo� O Z � � ARCHITECT'S DECLARATION 1 undersand my plana shall be used ns public retorts. OVER TWO AMPS SQ. FT. FLOOR AREA VSQ. FT. SIGNS ELECTRICAL F� / L a 6Y j �K < P� O V 3 N y}�, !Li1 a O 10 -„y (-Z'>' C y m Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that 1 am exempt man the Contractor's License Law for the following reason. (Section 7031.5, Business and Prafeasimm Code: Any city or county which "wrox a permit to construct, alter. improve, demolish, or repair any structure prior a its issuance, dm reyuircnhim lieanl forauch pennluo file asignedwammmm that he is licensed pursuant to the Provisions of the Contractors License Law (Chapter 9(wmmania, with Section]000)rf Division 3ofthe Business and Professions Code) ordain he is aempnhemnom and the basis farthealleged exemption. Any violminn of Sation ]031.5 by any epDlicant fore permit subjects the epplicanmoecivll penehy of not mote than five hundred dollars (1300). ❑ Las Owat(OflhepfOpeny.Ormy CmplOYCe9001111 WagCaef lhClr SolCtompeommoa, SPECIAL CIRCUIT/MISC. TEMP. METER OR POLE INST. POWER DEVICES SWIMMING POOL ELECTRIC VALUATION l OUTLETS - SWITCHES - FIXTURES NEW RESIDENTIAL ELECfR S .FT, -SQ.FT. TYPE CONSTRUCTION ywill do the work, and the stmcmm isnotimmnded proffered formic (Sm. 7=, Business and Prnfussians Cade: The Cantmcar'a License Law dues not apply m an owner of property whobuildsorimpoves themon.and whodoessuch work himselforthrough his own employem,povidW that such Impmvemermame not intendedoroffered fmsale. If, G RES. UNITS TO " however, the building orimpmvement is sold within am yearo eximpletion, theowner- builder will have the burden of proving that he did not build or improve for purpose of t QTY, - PLUMBING I''IiRMIT le.). ❑ Lasnwnerora<pmperty,nm exclusively wmmningwith licensed contmeama construct the project (Sec. ]044, Business and Professions CaleO The Comruam's License law does not apply town ownerof pmpeny who builds or improves flonew, and /I>t z e APN 6 pERMTT{SSUANCP. whocantmcts fmsuchprojects with acantraetor(s) Remand pursuartothes Contracar's License Lew. ALTER-DRAIN&VENT-WATER (EA) - FCC SUMMAR ❑ 1 ore oxcmpt under Sec, , R & PC for this reason BACK FLOW PROTECT. DI?VICEf DF. FTF.S SANITARY - Y N RECE11'I'a Owner Date DRAINS - F1.00R, ROOF, AREA, COND. WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN ❑ Ihemhyeffimt that l have a cmificate ofcoment to self -insure, or a cenifiateof Worked ComDensztiun lnsumnceoracerifiedcopymereof(See. 3800, Lab C.) which RECEIPT# FIXTURES-PHRTRAP PARK FTE Y N coversall employee's under this Permit.GAS Pollcyk - EA. SVSTI?Md INCA 0UI'LF,TS 10`7.CHIPT # B L IVIS T-.- GAS -EA. SYSTEM -OVER 4(EA) Company mp PLANCHECK ❑ Ceniliedempy ishembyfumdshed. GREASE(INDUSTRL WASTE INTERCEPTOR GRAUINC ❑ Certified copy is filed with the city impeclion division. CERTIFICATE OF EXEMPTION PROM WORKERS' COMPENSATION INSURANCE GRFASETRAP SOIL I'' SEWER - SANITARY - STORM EA. 200FT. OeNERIVIrr (This section need not lx completed Hire permit is for one hundred dollars (1100) odess.) WATER METER W/VEM'/ELECTR I certify that in the performance of the work She which this permit is issued, l shall not employ any peraan in any owner so as to become subject to the Workers' PAID ZCm,wihimn z 0— Lowsa(Celifnmia. Dote Applicant, NOTICETOAPPLICANT:If,wfwlr ingtNs Cenificnemffxemptian,youshould WATER SYSTE?MGREATING NEWRESIDENTIALPLMB. SQ.FT. Um Rccciptw TOTAL: F" VJ 1 Z U (] D. r C)IU+ become subjeuathe Worked Compensation provision of the Labor Code, you mow fordwim comply with such provisions in this pemtil shall be domed revoked. LENDING AGENCY construction I hereby affirm that there is a consction lending agency for the performance of the work for which this permit is issued (Sm. 3097, Civ. C.) Lender's Name Lenders Address - BUILDING IEE �• SEISMIC R?E TOTAL: ELECTRIC FEE QTY. MCCIIANICAL PERMIT FEE PLUMBING IEE FA. rA U z I certify that 1 have noel this application and state that the above information is torted. I agree to comply with all city and county ordinances and state laws relating to building construction, and herchy uatbariae rcprescnatives ofthis city to emeruDnn the above-memioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupcnit a against PERMIT ISSUANCE MECHANICAL FRE ALTER OR ADD TO MECH. CONSTRUCTION TA ,juJgoen¢,costsiwdcxpwmea which may imanywwywccmengainst said City AIR HANDLING UNIT (TO 10,000 CFM) im cn acnes of the gmming of this pertnit. Y G AIR HANDLING UNIT (OVER 10,(WCFM) _abilif Signaaoof App' am/Coutremor Deter EXHAUSTHOOD(W/DUCf) PAID HEATING UNIT (TO 100,00(1 BTU) HAZARDOUS MATERIALS DISCLOSURE Date Receipts Wi 11 the applicant Air future building cecupart same or handle humrdmus material as dermad by the Cupeninn Municipal Axle, Chapter 9.12, send the Health wW Safety HEATING UNIT (OVER 100,0181 BTU) T 1 Code, Section 25532(x)? 11 Yes Cl No VENTILATION PAN (SINGLE RFSID) Will the upplicanmr fears building occupant use equipment nr levices which emit ISSUA EDAT oOILER- COMP (31 IP OR 100,000 BTU) BOILER - COMP (OVER 110,IIfIfI BTU) dons or contaminants as defined by the Buy Area Air Quality Management mct? ❑ Yes ❑ No NEW RESIDENTIAL MECH. SQ. FT. I have mead the betatrons mweritls rtquiremems under Chapter 6.95 M the California l health &Safety Cade, Sections 25505,25533 and 25534.. l understandingr A D P1 A ' if the bui lding does not currently have a termal, that It is my melnmsibi lily In moti ry the .cc upum of the reyairememx which roust he mea prior a issuance of a Cerificute of Occupancy. ISSUED RX:, Owner or auth unzcd agent Date TOTAL: OF