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24481 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY ' CITY OF CUPERTINO HIR❑,BIN .-MECHA ICA RMIT NO, APPLICATION/PERMIT PLUMBING-h1ECBANICAI. 24481 A z$ 8 A BUILDING DIVISION BUILDING PROJECT IUN:NTIFICATIf1N L 4 4�XJ 11 BUILDINGADURFSS: SANITARY NO. APPLICATION SUBMITTAL DATE 22 33b I�rcrJQsl� Sl UNIT# FY LOTp OWNERSNAMI?: - PHONE: CONTRAC'JOR'SNAME: LIC NU' — $q Is• N �C` . 1\ NA] CONTROLp ARCHITECTIENGINHER: LICNO: ADDRESS' 1' ❑ 5zo C`T- le CONTACT: PHONE: I � QTY. F.hECI'HIC PERMIT PER BUILDING PERMIT INFO BLDG ELECT PLUMB MECH ...ZRMITISSUANCHI E] ❑ ❑ LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION pig Ihembyaffiwthnslemlicensedunderpmvislonso(Chapter9(commencingwish �00 Section 700()of Division 3 addle Business and Professions Code.and my license is in PANELS y full force and effect aZ License�C�la�s�s�1--Lick S I UP'10200 AMPS y a 1 y H 7 y Dam_LSA=LL_Contractor Iw 201-111(0 AMPS -fY- I G O 3 1 l Ci ZOUS • ARCHITECTS DRCLARAT[ON OVER 1000 AMPS SQ.FT.FLOOR AREA $ISQ.FF. O vi L.,O I understand my plans slid]be used as public records. © {�v LY u�I Licensed Professions SIGNS IiLF,CTRICAI. 7V OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC. II II xaOTE 0. I hereby affiw that I am exempt from the Commences License Law for the t 1� k 0 a1E t-rn ftdlowingreason.(Section 7031.5.Business and Professions Code:Any city or county TEMP.MLTER OR POLE INST. NO Q which requires a permit to conswn,alter,improve,demolish,or repair any atmelme f ab prior to its issuance,also requires the applicant for auchpermiltorileasigned smmment POWER DEVICES DATE I W�qO that he is licenecdpursnunt to the pmvisionaof the Communes License Low(Chapter 1)(contencing w hh Seer inn 7000)of Division 3ut be Businessland Proficovns Code) SWIMMING POOL ELL'CfRIC mVALUATION Vy3 r^y or that he is exempt hercfrnm and the basis for the alleged exemption.Any violation of tKQ Section 7031.5 by any applicant for a pewit subjects the applicant OUT'LETS-SWITCH ES-FIXTURES �}o a civil penalty of ( poo nt mom than five hundred dollars($500). pipe y, yemploymswidhwngesunc�irsolecampensmion, NI?AIRIEIDFNTIALELECIR _SQ.IT. n❑ I,axownemfthe n arm STORIES TYPECONS'TRUCDON a3� will do the amic,itnd mesaunurc is not mocridedmoffered forsale(Sce.70k4,Business and Professions Code:The Cammcmrs License Law does not apply to an owner of pmpeny who builds or improves thereon,and who does such work himsel for through his on employees,provided that such impm nrveemx arc not intended!or offered for aide If.. OCC,GROUP RES.UNI'T'S however,the building or improvement is sold witbin one year nfcnmpleriun,hic owner- TO EAI, builder will have the burden of proving that he did not build or improve ha purpose of selcJ' QTY, PLUMBING PI?RMIT FEE FLOOD ZONE APN ❑ Las rnfthe Seen ,Business and mmnsions hde: " Contowsto conswn the projm(See.]044,Business end Professions Cade:)The Commnofs License Lawdoes not apply men ownerofpmperty whobuildsorimproves thereon,and PERMITISSUANCE whocanwets for such projects with aconhaciods)licideadpursuantmthe Contmnar's ALTER (EA License Lou. ) FEE SUMMARY El1 oro exempt under Sec. B&P C lin This reason ';1 1 h1iI:S - IfACK PLOW Pk0'I'13Cf.DI?VICE SANITARY Y N Owner Dam RECHIM# DRAINS-FLOOR,ROOF,AREA,COND. WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y . ❑ IhertbY affiw thatlhave eceni0eete of mnxcnuo xlGinsum,oracmif¢em of Worket%Com nsesinn lnaumnce ore ttnifiedc IOXTURCS-PER TRAP RECEIn# oven V]employees ur it h�pg t. 9PY rhmwf(See.JgOp,lob CJ which PARK IEE RECEIfTp N c PolicyM— _ C��YSiS- 92 GAS-EA.SYSTEM-1 INC.40UTLES BUILDING DIVISION FEES Company - b, "� EI CeniOod copy Is hmeby huddled. GAS-IA.SYSTEM-OVER 4IEA) PLANCHECK FEE ' CenifieA copy is filed with the ciiy inspection division GRBASIVINDUSTRL WAST(?INTERCEPTOR GRADING FEE CERTIFICATE OF EXEMPTION FROM WORKERS' GRPASETRAP SOILS FEE COMPENSATION INSURANCE (Drissectionnecd nabecompleted if Nepewit isforone bacdreddollvs($100) SEW(?R-SANITARY-STORM EA.200FT. ENERGY FEE or less.) Icer that intoe perfowanceofthe work for which this pewit is issued.I shut[ WATER I IIATER W/VPNT/ELECR not employ any person in any manner so as to become subject to the Workers' PAID Z Cnmpcnsmlon Lnws of Gllifornia. Date WAIERSYSTP.MTREATINO - Dole RtcciptN' applicant z 0 NOTICET'OAPPLICANT:If,after making this CctliOcatoof Exemption,you should NEW RESIDENTIAL PLMIL SQ.IT. TOTAL: E-' [A become subject to the Workers Compensation provisions ofthe Labor Code,you must , a > forthwith comply with such provisions or thio pc.it shall be deemed revoked. BUILDING FEE I. U Q. FCONSTRUCTION LENDING AGENCY SEISMIC FEE s ;::) Z Thereby nfOrm dhnuhere is aconswnion lending agency for the performance of U O the work for which this pewit is issued(Sec.3(197,Civ.Cd TOTAL: ELECT RIC FEE LI. r.l lender's Name PLUMBING EEE U Lender's Address QTY. MECHANICAL.PERMIT FEE I certify that I have mad this application and duellist the sidedam.(information is MECHANICAL.FEE correct.Iagrecmon,comply and wishy simonize roposdaninenusaid smml entr upon gm PERM ITISSUANCE UZ building consned proert hertbyaection pmpmsemmiva ofthiscirytoemerupon she CONSTRUCTION TAX Uz ebov(We)time properlyfor inspection keeposex, ALTER OR ADD TOMI?CII. (W<)agree m save,indemnify and keep lawless the City of Cupertino ugair¢t Iiahiln Jgmcros,casts and expenses which may in any way accrue against said City AIR I IANDLING UNIT(TO I Q00(1 CFM) In nee of the gm min o thispermit. ♦ p AIR HANDLING UNU'(EVER 10,000CFM) - Signature of Applicun4Cnnwcmr Uma HXHAUSTHOOD(W/DUCD PAID IIAZARDOUS MATERIALS DISCLOSURE Hfl APING UNIT(TO 10001D BTU) Date Receips p Will she applicant or future building occupant atom or handle hazardous material m defined by the Cupertino Municipal Cale,Chapter 9.12,wilds,l Icahn and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL: aS� Cate,Section 25532(u)'f El Yes ❑No VENTILATION FAN(SINGLE RISID) BOILER-COMP(311P OR 1!0,000 BTU) ISSUANCE DATE- WilltheopplicamorfuwrcM1uildingoccupnmusecyuipmenmNeviceswhidtemis � � p� hmallous air cormminards as defined by the Bay Area Air Qualify Managemrnf(ffgg l pOILER-COMP(OVCR 100,000 BTU) r Al N ismer ❑Yes ❑No NEW RESIDENTIAL MECI1. SQ.IT. h I have read the maMom materials requirements ander Chapter 6,95 of the NOV 111992 California Health&Safety Gale,Sections 255(15,25533 and 25534. 1 understand that if tilt hailtling dnasnnl cumrntly hoveatenant,that it is my res,mbohilily to nniily she - ,!!s fT1111VV occupant of the rcyuiremm�le which must be mel prior m issuance Ufa Ceniftcnm of L''I I I Wr.VUI- ' Occupancy. Ownermimhorized agent Data TOTAL: ISSUED BY:-j-Ay'['�- LI)\k / - OFFICE