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25510 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OFCUPERTINOILIM G-F.LECIKICA I, PERMITNO. APPLICATION/PERMIT PLUMBING-MECHANICAL A C C Q O BUILDING DIVISION BUILDING PROJECIADEM1 I[FICA'I'ION L J J 1 BUIL. NGAD FSS: SANITARY NO. AIVLICATIONSUBMIITALDATE• WLOT NOn �� O 13115 ryAME' I - PHONE: CO RA R'S NAME: LIC NO: N/C CONTROL# ci © a e 1 •AliClll'1'EC'f/1?NGINEER: LIC NO: AD ESS. ❑ CON'1'ACI': PHONE: QTY. DIN BLDG HLE.LT ELECTRIC PERMIT FEE ISUILF= PERMIT INFO PLUMB MECH PERMIT ISSUANCE ❑ Iya ❑ ❑ LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL nizzI bereb affirm that l eon licenxJ under rovisions of Cha mr9(commencin JOB DESCRIPTION ltJ00 Y p P gwith Is100 Section](NXi)efDivision3MNe Businessland Professions Code,end myliccnse is in PANELS Ga f e and effect T�1gl�ryp�/iJAI' FZ .manse les Liap UP T0211(IAMI'S yQy ❑um�Contractar '+ `�'� 201-10MAMPS Fy ARCHITECTS UF.CLARATION SQ.lel'.FLOOR AREA $/SQ,FT. Z p y 3 OVER IM0 AMT'S CZ-0 I understand my plans shall be used as public records. .� [-.ytJ SIGNS ELECTRICAL LicenxA Professional y.CG OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. xOaF hereby alEm that I am exempt firm theConvu Co Lice ae Lew for tt n rJ 1 m3ay following rcexa fScetion]031.5.Rosiness end Profession Code: cit or coon TEMP.MITER OR POLE INST. f ,J u /Rys) t`��g whichrcyuiresepenrdttoconswa.cher,impmvgdemolish,orrepeiranysoumum POWER �( !� Cn�7 pnor l0 i¢issuance,also mqulrcs the applicant pemtit m file aligned statement a\J ty�00 that he is licensed pursuant the provisions ofihe Commences License Law(Chapter a of 9 fcomvsencing with Section of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION p _y or that he is exempt herefrom and the basis for the alleged exemption.Any violation of OU'T'LET(#-SWI'I CLIPS-FIXTURES dZoe Sealln.703I.5 by any applicant fora ctNEW RE.SIDIiNTIA1.ELECTR —SQ.1T.permit suhjes thenpplicanltoa civil pamoty of G not more dthan rive hundred dollars($50E. o ❑ Lasowner0fthepropeny,nrmyempinyees withwagesastheirsolccompensmion, STORIES, TYPE CONSTRUCTION a 322 willdothe work,and the structure isnot imendedmaffered fmxle(Sao 7044,Bulinus and Professions Cade:The Commctors License law does not apply to m owner of Property who buildsorimpro.es themom,and whaddes suchwork himxlforthmugh his OCC.GROUP RES.UNITS ownemploycm,providedthat such improvemcroseamot intendederoffnedforsale.If. however,the building or improvement is sold witimeneyesrofcompletion,the owner- T builder will have the burden of proving that he did not build or improve for purpose of sale.). ❑ Laxowoerofthepropery,em exclusively convecting with licensed contractors to QTY. PLUMBING PERMIT ITE fl.000_ZONE APN construct the project(Sec.7W4,Business and Professions Code:)The Contrnemr's License law does not apply loan ownerodproperty wholbuilds or improves thereon,and PERMITISSUANCE t whocommets forsuchprojectswith ammrammod licensed pursuam to the Contractor's pL'IER-DRAIN&VP.NT- A) License Law. WATER(F' FEE SUMMARY ❑ I amexempt under Sec. ,B&PC for this masen BACK FLOW PROTECT.DEVICE SANITARY O TY D N_ Owner - Dam DRAINS.FLOOR, ARBA,COND. RECEIPTp WORKMAN COMPENSATION DECLARATION SC11001.TAX Y N ❑ s.'Compenrtnrhmlhaveem.con ofed,meradf(Sec.38 o,Lm C.)c which FlXTIIREg- RECEIPf# PER 11tA1' Wnrkcri Compensation Insurance orecmified copy Nerrof(Sec.3800,LeBCJ which PARK hT:E YN covers all employee's anJU Nis permit - GAS-HA.SYS'IEM-1 INC.40IIT1LTS RECEIPT# Policy N BUILDING DIVISION FF.F.S Call GAS-HA.SYS'I EM-OVER 4(EA) PLANCHP.CK FEE Ifed copy Is herehy furnished. Catilied copy is filed with the city inspection division. - GREASHANDUSI'RI.WASTE.INTERCRPfON GRADING FEE CERTIFICATE OF EXEMPTION FROM WORKERS' GRIiASE'I'RAP SOILS FEE COMPENSATION INSURANCE (This modunneednat becompleted ifthe permit is fmone hundred dollars(SIM) SEWER-SANITARY-STORM EA.201 ENERGY FEE or leas.) I certifythat in rhe performance of the walk far which this permit is issued,Ishall WATER HEATER W/VEM'/ELECIR not employ any person n any manner so as to become subject to the Workers' PAID Compermotion Lawsof Califomia. Date WATER SYSTEMfIRP.ATING Data Receipt# O z Applicant O NOIME TO APPLICANT:If,after mall ng this Cmifi,em of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL: In Femme xuhject m the Worker's Compensation provixions of the lama,Cole,you must EFF^^^ orthwlth comply with such provisions or Ibis permit shall he deemed revoked, BUILDING FEE z CONSTRUCTION LENDING AGENCY _ I SEISMIC PER 1 hereby affirm that them is a construction lending agency for the performance of V the work for which this Permit is island(Sao 1097,Ci¢C.) TOTAL: ELECTRIC IF.E Lender.Name IT. Lenders Address QTY. MECI IANICAL PERMIT FEE PLUMBING FEE 0 V I certify that I have read this application and lux Nat the above informal.isM[CIIANICAL FEE >" 4 correct.I agree to comply with all city utM county mebrorcas and stem laws relating to PERMIT'ISSUANCE.. building comwction,and hereby initiative representatives of this city to enter upon the V above-mentioned property for inspection puryoxs. ALTER OR ADD TO MECH. CONSTRUCTION TAX Wo)agree to save,indemnify and keep humanities the City of Cupertino against liuhiliti ms,costa and ox •noes which son manywayna:rucaguinstsaid City AIR HANDLINGUNLT(TO 1g000CFM) in ca v a l cal ingr permit. - AIR HANDLING UNIT(OVER 10,0M CFM) �1 Signa man t 6 Dain FJ(HAUST HOOD(W/DUCI) PAID RUOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,1100 BTU) Data Receipt# Will the applicant or future building occupant store or handle baurdous material RLATING UNIT(OVER IOO,tUp BTU) IOTA : m defined by the Cupertino Municipal Crile,Chapter 9.12,sand he Health end Safety Code,Scotian 25532(.)? VENTILATION PAN(SINGLE RESID) ❑Yes ❑No Will the epplicanmr future bei Wing oeupum use equipmenmr devices which emit BOILER-COMP LIHP OR 100,000137U) ISSUANCE DATE >-� Imnmlres air cunm umants as defined by the Buy Area Air Quality Management BOILER.COMP(OVER lM,0M BTU) "Dlxvlcft ❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. I have read the htearmus materials requirements under Chapter&95 of the A� Califomia HW th&Safety Code,Sections 25505,25533 and 25534.1 undersand Nat 7 n if the building does not currently have a mmnt that it is my responsibility to notify the ✓�/sr q occupant of the rcitmodu ants which must be soil prior to issuance of a Certifieam of Occupancy. r Owner of tmthimidd.gem Date T'O'1'A1.: ISSUED BY: OFFICE (�