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25307 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINOBQII'D1NC.-ELv PERMIT NO. APPLICATION/PERMIT PLUM;IING-MECHANICAL 25307 5 O 0 7 BUILDING DIVISION BUILDING PROJECI'IDENTIFICATION JJ 1 BWLIA(GADDRES/SSS�a SANITARY NO. APPLICVRONSUBMITALDAIP OgQ LOT# I O N' SN M 1� - - ;XHONFt CONTRA NAME:�/� LIC NO: o gl. /✓}I`J•V1fVd\L��'ll�/ N/C CONTROLp �ARCIII'1 'C /ENGIN ER: LIC NO: ADDRESS: El CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO BLDG ELECT' PLUMB µ[C11 PERMIT ISSUANCE � � 1171`', LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL I hereby affirm that I am liecacd under mvisionsofChat 9(commencin with TOB DESCRIPTION ❑C'L Y P per (commencing Licensw00 Section'l0Xd.fDivision 3efma Business and Professions Codc,and my license is in PANELS <Zjjffect , ceande . 1 •�.� 1, \A\ V1g- i!7 <Z, Liccac Clava Lic.N UP T0200 AMPS <.LJ�'I V�/♦`+�(.•r'r��(�Q, m?y Dene Contra, 201-1000 AMPS SQ.ITT.FLUOR AREA $/SQ.4T. ZON=E ARCHITECT'S DECLARATION OVER 1000 AMPS 0Z_,q I uodersmnd my plans,hall a oaduspub en,cmd,. W SIGNS ELECTRICAL <N , I.ilenacd Professional awxQ OWNER.BUILDER DECLARATION SPECIAL CIRCUIT/MISC. KOaO I hereby affirm Nm 1 am exempt from me Comncmrs License Law for she W 3 L,.ti following reamn.(Section 9031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST. F_ < which"i ircs is p:rm i to construct,nae,.improve,demolish,or mpair any tumours LL EN}� prior to its issuance,alm requias sire applicant for such permit to file a signed statement POWER DEVICES C mar he is licensed pursuant res the provisions of Ne Convectors Luras Lawns CM aao ygnmmencing with Sretion]000)af Divisian3of she BusinessmdPra(essions CodeI SWIMMING POOL ELECTRIC VALUATION W=ti or that he is exempt therefrom and the basis for she alleged exemption.Any violation of OUTLETS-SWITCHESFI%TURES -FMIA L E © I N l F Z< Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of I me man five hundred dollars($500). �yyy�q NEW RESIDENTIAL F.LHCIR -SQ.1-7. t T HI S ECONSTRUCT[ON � � asowncro0hepropenY.ormycmployres with wagesastheirsolecnmpnsmion, a til dothcwork,and the strortum isnot intended or offered for side(Sec. Business W I'mfessions Code:The Contractor's License law does not apply to an owner of popny whobuildsorimprove,thereon,and wbodoe,such workhor elf eramghhLs on cmployaes•provlded that such improvements anot intandedoroffered forsale.If. DAT OCC GROUT' is R .UNITS hore wever,the buildingor Improvement is sold within one ymofcompleuon,the owner- TOTAL: builder will have the burden of proving that he did nos build or improve for purpose of si1e')' QTY. PLUMBINGPERMIT FEE FLOODZONE APN ❑ I.usownerofinepropeny.amexclusivdyconsmcsingwimli..dc..0 1ors10 consumer the project(Sac.7(44.Business and Professions Code:)The Convector's I.icenm Lowdce,nolapplytomownerofpropenywhobuildaorimprovesrhereon,and PERMIT ISSUANCE who contractsforsutb projects will accountants)licensed pvrsuantrmM Convonor's ALTER-DRAIN&VENT-WATER TA) FITE SUMMARY Liccnm law. ❑ 1am exempt under Sec B&PCfur this remon BACK FLOW FIRM En.DEVICE ( TSIU1:FEES SANITARY Y N Owner Date DRAINS-FLOOR.ROOF,AREA,COND. RHCHIPTM WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N ❑ I hereby affirm that l have a can fiesta ofconam to self-insure.or a ceniftcare of FIXTURES PER TRAP RECEIPTM arkers'Compensation Insurance a there off canified copy theof(Sec.3800,Lab C.)which PARK FEE Y N RECEIPT al covers all employees under this ennif GAS-EA.SYSTEM-]INC. OUTLETS BUILDING DIVISION FEES Policy g Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE ❑ CenifedcopyisherehyfnnishW. ❑ CeulfiW copy is filod with the city inspection division. GREASMNDUSTRL WASTE INTERCEPTOR GRADING FEE CER1TRCATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS 4EE COMPENSATION INSURANCE (Phis section need nothe completed ifthc permit is foronehundrel dollars($10)) SEWER-SANITARY-STORM FA.200F1'. ENERGY FEE or less) I certify that in the perfomtanca ofine work for which this Permit is issued.I shall WATER HEA HER W/VIiNT'/ELECTR not employ any person in any manner m a to become subject to me Workers PAID Compcnsalialawsof Califomia. Data WATER SYSTEMO`REATING Date RecciprM Q z Applicant, Z O NOTICE TO APPLICANT:If,after making this Canificere of Exemption.you should NEW RESIDE- IAL PL.MB. SQ.FT. TOTAL: y become subjeO a me Workces Compensation provisions of me Labs Code,you must � � forthwith comply with such provisions or this Permit be deemed revoked. BUILDING ItiE [� CONSTRUCTION LENDING AGENCY SEISMICFEE 7 Z I hereby affirm bthat there is a construction lending agency for the performance of U O the work for which this permit is issued(Sec.3097,Civ.CJ ELECTRIC FEE Lender's Namev PLUMBING FEE u" F lander,Address QTY, MECI IANICAL PERMIT FET. t..) 1 ecnily mat 1 haves road thi,application and state mar me aMve infarmmian is ,�. MECHANICAL FET; / >" P4 coal.logrremcomply with ell city and county oNinances and stare laws entering to PERMIT ISSUANCE f" a. buildingreastmction,add hereby andorre a,00carmses ofthis city loenterupon the CONSTRUCTION TAX U Z above-mentionW property for inspection purposes. ALTER OR ADD TO MECIi. (Wa)agree to save,indemnify and krep harmless me City of Cupertino against liabilities,judgments,coda it expenses which ray in my way necroses tmid City AIR HANDLING UNIT(TO@.mDCFM) inco�nceofthematingofthispermit. � fj AIR HANDLING UNIT(OVER 10.000 CFM) 11 1 Si�bfanVl mwax1 - Tr TD� EXHAUST IIOOU(W/DUCI) PAID HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 110,(100 BI'U) Data Receipt p Will the applicam or lama heildo,oecupont amre orhandle haznnlovs material HEATING UNIT(OVER 100,000 RTU) 'fOTAI.: is defined by rhe Cupertino Municipal Core,Chapter 9.12,and the Health and Safely code,section 25532(a)1 VENTILA9'ION PAN(SINGLE RESID) ❑Yes ❑NO ISSUANCE DATE Will rhea licaotmfmurebuildin rose tordeviceswhichemit BOILER-COMP OHP OR 100,000 BTU) pp !by the Area Air air mnurtinen¢ns dcOnW by the Bey Arca Av Qudity Management BOILER-COMP(OVER 100.000 BTU) pq p dDistrict? r I D ❑Yes ❑No NEWRESIDENTIAL MF.CII. SQ.FT. I have read the harmdous materials requirements under Chapter 6.95 of the r JUL 1 2 _^ California I health&Safety Cade,Seen.,25505,25533 and 25534. 1 undermnd mal p�{/6 i 9D♦(/I{I�!', it the building mc,not currently have a tenant,that it is my responsibility to notifylbc h! acupant of Ote requirement,which n a,t be mel prior to issuance of a Certificate of �'♦ �7)r�}'.� _ Ikcupun'. Owneror uuthuriaW agent Date ejTA4j I si ISSUED BY: