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26003 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO "In PERMIT NO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 26003 BUILDING.PROJECT IDEN'HFICATION BUILDING ADD RESS: - rx.a)C - SANITARY NO. ADPL^�%��MfITAL DATE /070M (/0,J/A UNIT# LOT# OW ERS ME: PHONE: CONTRACT9R'S NAME: LIC NO: NIC CONTROL.# ZS O wr uo11 oQ AR HITEC NGI LIC NO: ADD SS: El CONTACT: PHONE: .0 60 QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO J ere SSG 7 bol o PERMIT ISSUANCE BLDG ELECT P U MECH El 1:1 BLDG LICENSED CONTRACfORSDECLARATION APPLIANCE$-RESIDENTIAL LOB DESCRIPTION p-.z thereby eff Division 3 ofthnsedunw,andvisionsofCTapter9nd(commencing se with 00 Section]0007 of Division 3 of the Business and Professio Code,and my license is in pgNE1$ , a 1C; full Locrusceand Ufe q � ♦ l ,ate/ Fz❑ License Ila-s �_ Lic.q n IIP T0200AMPS \(�f���{a�� ��\`__l!1+ vary Dam Contractor 20I-1000 AMPS zON� ARCHITECTS DE -ATI OVER IMAMPS SQ.PI'.FLOORAREA $/SQ.FT. O z-0 I understood my plans shell be used as pu tic records. Pyt .N SIGNS ELECTRICAL g ...41 Licensed Professional ccg OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. KOii FU 1 hereby-111—that I a m exempt from the Contractors License Law far the W✓0 ma fallowing reason.(Section 7031.5.Business and professions Code:Any city or county TEMP.METER OR POLE MST. �n which requires a permit to construct,alter,improve,demolish,or repair any structure POWER DEVICES pdorm its issuance,also requires the applicant fmsuchpmothr,file a signed stammenl 0.<O thm he is licensed pursuant to the provisions of the Cotnmctor's License Lew(Chapter 0E' 9(commenctng with Section]000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION iiW((_y or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FI } Section 7031.5 by any applicant for a ronit subjects the applicant toe civil penalty of Qns [more then fere hundred dollars($5W). NEW RESIDENTIAL EL ISQ.FT. STORIES TYPE CONSTRUCTION W C ❑ 1,asowneroftheproperty,ormyemployeeswi0wagesastheirsolecompensauon, y will do the work,and the structure is not intendedoroffered for sale(Sec.7044,Basinesspt and Pmfessions Code:The Contractor's License Law does not apply to an owner of I _ Y i property who builds orimproves thereon,andwhodoes such workhimselforduoughhis own employces,pmvided thatsuchiniprovemmtsarenotintendedoroffeted mrsale.If, OCC.GROUP REB.UNITS however,the buildinger improvement is sold within oneyearofcompletion,theowner- , builder will have the burden of proving that he did not build or improve for purpose of _ sale.). [11,as ownerofthepropedy,am exclusivelycontracting with licensed contrectersto QTY] PLUMBING PERMIT FEE FLOOD ZONE APN nslruct the project(Sea.7044,Business and Pmfesslaos Codc:)The Contractor's License Law dcesnotepply manownerofproperty whobuildsorimproves thereon,end PERMIT ISSUANCE who contracts forsuchprojects withacommcmrts)licensed pursuant to the Contractor's ALTER (FA) License Law. FEE SUMMARY ❑ I am exempt under Sec. ,B&P C for this renson BACK FLOW PROTECT.DEVICE OUT OE E SANITARY Y N Owner Data DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT# WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N i ❑ therebyafflrmthatlhaveacenificateof cons entmealf-insure,oracanifrcareof FIXTURES-PER TRAP RECEIPT# Immuneor Warkers'Compensation Immune a certified copy thereof OSec.3800,Lab CJ which PARK FEE Y N Poet cY�l em�lLay�e^under thiaw Civ r GAS-EA.SYSTP.M-I INC.40UTLETS BUILDING DIVISION FEES Policy# GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE ❑ Certified copy is hereby famished. 3a Certified copy is filed with the city inspection division. GREASEBNDUSTRL WASTE INTERCEPTOR GRADING FEE CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE COMPENSATION INSURANCE (This section need not he completed ifthe permit is forone hundred dollars($100) SEWER-SANITARY-STORM EA.200FU ENERGY FEE or less) I certify that tithe in a any woofer so as for whichthisiubjecpermit o issued,I shallWorkers' WATER HEATER WNENT/ELECIR not employ any person in any rummer so az to become subject to the Workers' PAID Z Compensation laws of Celifomin. Date WATER SYSTEM/IRFATING Data Receipt# NOTICE a t NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.IT. TOTAL: V] become subject to the Worker's Compensation provisions of the Labor Code,you must forthwith comply with such provisions.,,his permit shall be deemed revoked. BUILDING FEE Q CONSTRUCTION LENDING AGENCY SEISMIC FEE Vz I hereby affirm that there is a construction lending agency for me performance of the work for which this permit is issued(Sec.3097,Civ.C.) ELECTRIC FEE (A Lender's Name - PLUMBING FEE 0 F Lender's Address QTY, MECHANICAL PERMIT FEE U I certify that I have read this application and slide that the above information is MECHANICAL FEE correct. l agree to comply with all city and county ordinances and slate laws relating to PERMIT ISSUANCE Uj buildingeonso-uctlon,and hereby authorize represenmtivesofthis city to timer upon the CONSTRUCTION TAX U 'z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. (We)agree to save,indemnify and keep harmless the City of Cupertino against lixbtlitics,judgments,costs andex,moves which may many way arecrueagainatsaid City AIR HANDLING UNIT(TO 10,000 CFM) in consequence oflhe rnming fthis permit. AIR HANDLING UNIT(OVER 10,000 CFM) Si tore A Iican4Comm tm EXHAUST HOOD(W/OUCT) PAID HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt# Will the applicant or future building occupant arum or handle hazardous materiel HEATING UNIT(OVER 1W,IXq BTU) TOTAL: as defined by the Cupertino Municipal Code,Chapter 9.12,end the Health end Safety Cade.Section 25532(x)? VENTTLATIO MCLEEESI ❑Ym ❑No ISSUANCE DATE Will theapPlicentorfuwrebuildingnccupantuseequipmentnrdevices whichemit BOILER- OMP(3HP OR 100,0008 ) havardous air contaminants as defined by the Bey Area Air Quality Management I Diso-tc0 BOIL -COMP(OVERI ❑Yes ❑No NEW ESIDENTIALPAFD I have read he hazardous.medals requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533 and 25534.I understand that VAN 11 1996 if the building does not currently have a tenant,that it is my responsibility to notify the Ocupant mite re,timemerds which most b,met prior to issuance of n Certificate of ccupancy. �S',. Owner or authorized agent Date TOTAL: ISSUED BY: OF