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27524 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRIAL PERMIT NO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 27524 BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS:911 / / SANITARY NO. APPLICATION SUBrMITTALDATE !✓ UNIT# LOT OWNERS NAME: PHONE: CONTRACT'OR'S NAME: LIS1 N/C CONTROLX ®ARCHITECDEN INCER: LIC NO: ADDRESS: CONTACT: PHONE: BUILDING PERMIT INFO QTY. ELECTRIC PERMIT FEE BLDG ELECT PMECH PERMIT ISSUANCE ❑ ❑ Q ❑ LICENSED CONTRACPOR'SDECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPcfTIOON p a'Z Thereby affirm that I arm Inercused CENSEDCONTRA TORSsDECLA NATIO (commencing with �Iw^f nr' LVOO Scctia 7000)of Division 3 of the Business end Professions Code,end my license is in PANELS Qfull enJ effect. m r ase Cho LiaN UP T0200 AMPS 1 co D te Contractor a'y Oy 301-1000 AMPS z0o,z ARCHITECTS DECLARATION OVER 1000 AMPS SQ.Fp.FLOOR AREA S/SQ.FT. OZ-0 I understand my plans shell he..it m public racaTds. F rn SIGNS ELECTRICAL 6 icemed Professional OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. 1 hereby affirm chat I not exempt from the Conrmctoes License Law for the 1131 Y.O co following reason.(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST. ,J which requires a permit to eumi aper,improve,demolish,or repair any structure - EY7 priorto its issuance,also requires the applicant for such Permit file a signed statement POWER DEVICES ce K G p chat he is licensed pursuanuo the provisions of the Contractor's License Law(Chapter p'Xcz9(commencing with Section7000of Division 3ofche Business and Professions Code SWIMMING POOL ELECTRIC {y ) VALUATION ct1^y or that he is exempt M1erefromund the basis for limidleged exemption.Any Golan..of I.ZY Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of OUTLETS- SWITCHES-FIXTURES G not more than five hundred dollar(1500). NEW RESIDENTIALELECfR 5 FT. W—w ❑ Luawnerand the 70401.eumian, Q' STORIES TYPE CONSTRUCTION L3— will clothework,and the he Contractor ianendedm offered fs not apply to an Business end artyProwhiolo Cade:The Contractor's License Lew such not apply m an owner of property whnhuildsorimproves thereon,endwhodces such work himselforchmugh his however.the buildingJedprocroiml is mid nuerene earoedoroffered the owner. OCC.GROUP RLS.UNITS builder ..the building burden of.mem is sold within one year or improve for the owner builder will have the burden of in that he did not build or ire TOTAL: moving prove for puryose of We.). ❑ I,asawner of the pmperty,vm ex<Imivelycontrnming with licensed convmmrsm QTY. PLUMBING PERMIT FEEF100 NE ANN construct the project(Sec.704q Business and Professions Code:)The Contractors License Law does not apply to on owner of property who builds orimpesthercon,and PERMIT ISSUANCE O'• mv whence Law.linmch projects with aconwccor(s)licensed pursuant Contractors ALTER FA FEE SUMMARY License Low. (- 1 ❑ I am esemO uMer Sec. ,B&P C for this reasonUUISIUE MES BACK FLOW PROTECT.DEVICE ITARY Y N Owner Dam RECEIPT# WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR.ROOF,AREA,GOND. SCHOOLTAX Y IS six ❑ I berebyefOrso that l have a cenificace ofconsem to self-insure,Ora certificate of v REC. WorkersCompensation lruuranar ceucertifiedcopy thereof(Sec.380/,Lab CJ IP which FIXTURES-PER TRAP PARK E Y N covera all employer's under this permit. GAS-RA.SYSTEM.I INC.4 OUTLETS R Policy# BUILD4DIjrnfSIONFE Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHfE KFEE ❑ Certified copy is hereby famished. ElCertifiml copy is filed with the city inspersion division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FE CERTIFICATE OF EXEMPTION FROM WORKERS' - GRBASETRAP SO Slti COMP12NSATION INSURANCE (This section need not b,rmn,med But,pavan is for one hicndroddollms($100) SEWER-SANITARY-STORM EA.200FT. G or less.) I cevtfy that in the performance of the work for which this permit is issued,l shall WATER HEATER WNENT/ELECIR not employ any person in any m as to become subject to the Workers' pplp z Compcn..tion Lawsof California.manner so WATER SYSTENLTREATING to Receipt# Applicant O C) NOTICE TO APPLICANT.If.after motion,this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. OTAL: became subject to the Workers Compensation provisions of the Labor Code,you must Fa' ; fard iN comply with such provisions"is permit shell be deemed revoked. BUILDING w z CONSTRUCTION LENDING AGENCY SEISMIC FEE 5 1 hereby affirm that there is a construction lending agency for the performance of ELECTRIC PEE U O the work for which this permit is issued(Sri.3097,Civ.CJ LTti pr Lender's Nvme PLUMBING FEE 0 U Leader's Aaarcsa QTY. MECHANICAL PERMIT FEE. 1 certify Nat I have read this application and cute that the all information is correct.I agem to comply with all city and county ordinances and scam laws relating to PERMIT ISSUANCE. MECHANICAL FEE ry building consuvaion,and hereby vuchosiu representatives ofchis city menter upon the CONSTRUCTIONTAX L) 7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. C (We)Ogre.ca save,indemnify and keep harmless the City of Cupertino against liabilities,judgments.costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,"CFM) e of the granting of this permit. AIR HANDLING UNIT(OVER 10,010 CFM) Signe ommmnr Date EXHAUST HOOD(W/DUC) PAID HAZARDOUS MATERIALS DISCLOSURE I[EATING UNIT(TO I0t000 BTU) Date Receipt# Will the applicant or future building Occupant store or handle hvardous mateom BEATING UNIT(OVER 100,000 BTU) TOTAL: as defined by the Cupertino Municipal Code,Chapter 9.12.end the Health and Safety Cade.Section Ya5l a)?,❑No VENTILATION PAN(SINGLE RESID) 13 Yes ISSUANCE ATE Will N.a licnntnrfmure huilJin tusec BOILER-COMP(JIIP OR 100,000 BTU) � � � p� pp gby then qea AirtQualit Muccochemit - lJ © huzordovn air ammminenrs as defined by the Bay Area Air Quality Management BOILER-COMP(OVER IIX1,000 BTU) DistricR 11 Y. ❑No NEW RESIDENTIAL MECH. SQ.FT. FEB 119QQQ��5ss x 5 1 have mad the lacrom nus materials sequlmments under Chapter 6.95 of the Celifomia Health&Safety Cade,Sections 25505.25533 and 25534. 1 understand that if the building does not currently have a wnant.that is is my responsibility to notify the - GTI1 1r UI. (aVrrhIINU occupant of the rcquirements which must h met or to issuance of o Cer ificme of V Occupancy. - Owner err towltmivW agent Dom TOTAL: ISSUED BY: OFFICE