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25823APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY CITY OF CUPERTINOH - La PLUMBING. -MECHANICAL PHRMITNO. 25823 BUILDING DIVISIONAPPLICATION/PERMIT BUILDING PROJECT IDENTIFICATION' BUILDING ADDRESS SANITARYNO.JA�MICAIIONSUHMITFALDAIU' UNIT! LO"ri, � I10NE: :3 I�� J A R'SNAME: LIC // 3 NIC � CONfROI.N ARCHITECT[ENGINEER: LIC NO: Rus ��ct-fie Ste- CONTACT: PHONE:. QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO BLDG ELECT' PLUMB MECH PERMIT ISSUANCE ❑ LICENSED CONTRACTOR'S DECLARATION APPLIANCES -RESIDENTIAL 1011 DESCRIPTION I brom affirm that 1 am licensed under provisionsofChapter9(commencing with Section 700(inf Division 3 oflhe Braturssand Profes,ian, Code, end my li,tiumis in PANELS y� 1.11force and effect. License Inds ILi<.! IF UP T02fXlAMPS I\'■TT\\ at &--:Z— Conor loon 201-INKAMPS A R R I/IQ. FT. ARCHITECTS DE RA ON OVER 11100 AMPS ^ I understand my it hull k used as public mvmds. U 1 _ SIGNS ELECTRICAL Id ) hiccnsd Professional II OWNER BUILDER DECLARATION SPECIALCIRCUR/MISC. l� Lv1 I hereby affirm That I not exemia, from the Contractors License Law for the following Humn. (Section 7031.5, Business and Professions Cade: Any city or county TEMP. METER OR POLE NIST. which require, a permit to com,(uct, alter, improve, demolish, or repair any structure filegndm ixsuance,.),. res the applicant for such permit m nsi esesteent ,fimmitquimppl POWER DEVICES that he is licensed pursuant to the provisions of the Contractors License Law (Chapter yAL 9(cmnmevcing with Section 701K) of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC or that he is eacmpt therefrom and the basis for the alleged exemption. Any violNon of bjece ant m Section 7031.5 by any applicant for u permit suts th pplicae civil penalty of OUTLETS - SWITCHES -FIXTURES not mortthanfivehundred dollars NEWRFSIDENTIALELECTR _SQ.FT. STORIES TYPE CONSTRUCTION myea0). ❑ Las rofthepropeny.ofmyempinded with wegcsndthei( 0,Ft.B ,roes, will Bothework, and the structure is not intendedearoffered (Sec. 7044. Business dosmote(Sec. and professions Chale: The Contrvetrr s License Law Joel not apply to an owner of - propenywhobuildsorimprovesthereon, andwhodoes such work himselforthrough his OCC GROUP RFS. UNITS that such impnvementsenot inteadedorofferW for sale. If. employees, pvided m however, the building or improvement is sold within one yearofcompletion, heov n,r- TOTAL: builder will have the burden of proving that he did not build or improve fm Purpose of Hilt.). ❑ I,ndownernf the progeny,umexdusively, contracting withlicensed convactorsQTY. to PLUMBING PERMIT FEE FLOOD'l.ONE APN cusmarto are nailer, (See. 70,14. Baseness and Prnfessintss Code:) The Convectors License Law dues no, applym an owncrofpropeny who builds m improves thereon,and PERMIT ISSUANCE whocmnrams for such projects with aconvecho((s) licensed prnaanno the Contractors ALTER - DRAIN&VENT -WATERFA ( > FEE SUMMARY License Law. ❑ I am exempt under Sea , B & P C fm this rtamn BACK FLOW PROTECT. DEVICE OUTSIDEFEES SANITARY YN RECEIPT p Owner Date WORKMAN COMPENSATION DECLARATION DRAINS- FLOOR, ROOF, AREA, COND. SCHOOLTAX Y N ❑ Thereby alfi(mthat l have a certificate ofconsem to self -insure. or a cenlhcthe of FIXTURES - PER TRAP RECEIPT! PARK FEE Y N RECEIPT p Workers Compensation Insurance or a cenifid copy therein Sec. 3800, tab C.) which aall employee's under Iris psmrit. Pors licy! GAS - EA. SYSTEM -I INC. 4 OUTLETS BUILDING DIVISION FEES Company GAS - EA. SYSTEM -OVER 4 (FA) PLANCHECK PEE ❑ Ccnified copy,, hereby famished. GRADING FEE ❑ Cenilied copy is Eled with the city inspection division. GRFASEANDUSTRL WASTE INTERCEPT OR CERTIFICATE OF EXEMPTION PROM WORKERS' GREASETRAP SOILS FEE COMPENSATION INSURANCE ENERGY FEE (Thi,.1nonudnot be completed ifflepe.it is future hundred doll. (SIM) SEWER - SANITARY - STORM EA. 200FT. or Real I certify that in the performanceof the work for which this permit is issued, Ishall WATER HEATER WNENT/ELECUR so not employ any peson in any manner as to become subject or ,he Workers' PAID Compmeaditnlawsof Califnmia. Date WATER SYSTEM/IREATING Dam Receipt! Applicant NOTICE TO APPLICANT:If. after making this Crnifictte of Exemption, you should NEW RESIDENTIAL PLMIL SQ. FT. TOTAL: become subject to Ne Workers Compmrahon provisions of the labor Code, you must foMwi h comply with such provisions or this permit shall be deemed revoked. BUILDING FEE SEISMIC FEE CONSTRUCTION LENDING AGENCY I hereby affirm chat hem is a construction tending agency for the perfomunce of TOTAL: IiLCCTRIC FEE the work for which this permit is issued (Seo. 3097, Civ. C.) lander', NamePLUMBING - ,ander', Addmsa QTY. MECHANICAL PERMIT FEE FEE I candy,lain 1 have read dr, application and shim then the above infommtlon is MECHANICAL FEE contact. lugremocr,mply with all city and county nNinunces and nine lows mlehingm PERMIT ISSUANCE buildingconsvuction, and hereby authorize representatives ofthis city to emer upon the CONSTRUCTION I'AX above-mentioned progeny For inspection Purposes. ALTER OR ADD TO MECH. (We) agree ,o as indemnify end kap h less the City of Calendar, ageing liabilities, ad a. costs robe, hes whi ma nanywayacmeagmns,.id City AIR HANDLING UNIT (TO 10,000 CF) onseque h ti is pc AIR HANDLING UNIT (OVER 10.000 CFM) PAID igr reel APPlinmt/Contract ¢ C%HAUSI'll(lOD (W/OUCII HAZARD US MATERIALS DISCLOSURE HEATING UNIT (TO 100,000 BTU) Dem Receipt Willtheapplicantorf um building mcuaton store or handle ham(dous material HEATING UNIT (OVER 100,1%p BTU) as defined by the Capenl Municipal Code. Chapter 9.12, and the Health and Safety Cede, Section 25532(x)? El Yea 0 N VENTILATION FAN (SINGLE RESI)) ISSUANCE 'I', BOILER- COMP QHPOR 100.0001HU) Will thcupplicant orfuturebuildingoverpant useequipmenordevices which emit Incursion, air c rr mminm. nd defined by the Bay Arta Air Quality Maaegemedt BOILER - COMP (OVER Bill BTU) District? ❑Yes ❑ No NEW RESIDENTIAL MECH. SQ. FT. ph P4 p 8 Y' I have read the hmmdous materialsmaterialsrequirements under Chapter 6.95 of the Culifomia11vahh&Safety Cde.Sectiore25505,25533and25534. 1undenim Net if the building does not currently have a tenant, that i, is my responsibility to notify the �� n 1 �9, caper of ,he rtquirementa which most be met prior m ixsuance of a Certificate of + Occupancy.J ISSUED Owner or authorized agent Date TOTAL: I OFFICE APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINOB - --' PHRMITNO. BUILDING DIVISIONAPPLICATION/PERMIT PLUMBING.-MECHANICAL 25823 BUILDING PROJECT IDENTIFICATION' BUILDING ADDRESS SANITARYNO. JA�MICAIIONSURMITFALDAIUUNI'1'a LOTa � O Mti. // I10NE: 2 A R'SNAME: LIC yH- I -- r J // 3 N/C CONfROI.N ARCHITECT[ENGINEER: LIC NO: RESS �tG L.L_��- ❑ CONTACT: PHONE: . QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO BLDG ELECT PLUMB MECH PERMIT ISSUANCE El ❑ ❑ LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL 1011 DESCRIPTION mmz Haroebyamnaduc lamlicemeJandcrpr..annnsofChapter9(commencing with u100❑ Section]INN)nf D,suinn 3 addle Basinessand Professions Code,and my limmeis in PANELS T� �ZU Licnse ll ant effect 1-2, �� I■T\ FZW License las_ _ Lie . a UP T0200 AMPS bo<s- me Conins., 201-1000 AMPS FyZ ARCHITECTS DE RA ON ^ R R 5/SQ.FT. _OZyG IunJminnJ my plans shall be used as public records. OVER I000AMP5 d - f'�4 Licensed Pn I.,ohnal SIGNS ELECTRIC ,-- I I ) tJ � p.{ �,,6 OWNER BUILDER DECLARATION SPECIAL CIRCUIT/MISC. Lv1 J � Y x0iu I hereby affirm that I am cacmpt from the Contractors License Law for the G 3 LL h following mount.(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST. t .1 which ampares a p.it to construct alter,improve,demolish,or repro any swurt cr zn>5 pdorsoisixsuancaal,o reclaims the applicant for such permit m file a signed statement POWER DEVICES ,K<O that he is licensed pursuant n the provisions of the Contractor's License Law(Chapter SWIMMING POOL ELECTRIC uao� 9(commencing wllh on p)of Division 3 of the Business and Pros ions Code) VAL m=m or that he is cacmpt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHFS- FZ.QSection 7031.5 by any applicant far a permit subjecstheapplicant ma civil penalty of M(TURFS E4o not mart thanfrvehaprolJolhroo). NEWREMDENTIALELECTR _SQ.FT. STORIES TYPE CONSTRUCTION W f—o CII,asowncrofthepropleny.ormyemyemployees with wegcsastheirsolecompertsation, W will point work,and the s0ucmre is not intended oroffered forsale(Sec.]094.Business and Rnfcssinns Cade:The Contractor's License Law docs not apply to an owner of - propenywhobuildsorimprovesthereon,andwhodoes such work him rdinihmugh his employers,provided re that such improvementsanot intendedoroffered for sale.If. OCC GROUP RFS.UNITS however,the building or improvement is sold within one yearofcompletion, browner- TOTAL: builder will have the burden of proving that he did not build cur improve for puryase of sale.). PLUMBING PERMIT FEE ❑ I,reownerof the prapeny,umexdusively, contracting withlicensed v conadoQTY. rs to FLOOD ZONE APN construct the pmJwt(Sm 7044,Business and Podo iotas Code:)The Contractors License Law dams not applym an ownerofpropeny who builds m improves thereon,and PERMIT ISSUANCE rect whoamts for such prots jecwith rs acormactor(s)licensed puuanno the Contractors ALTER-DRAIN&VENT-WATEREA License Law. ( > FEE SUMMARY ❑ I am exempt under Sea ,B&P C for this reason OUTSIDEFEE;q BACK FLOW PROTECT.DEVICE SANITARY Y N Owner Dam RECEIPT p DRAINS-FLOOR,RODE,AREA.COND. WORKMAN WMPENSATIONDECLARATION SCHOOL TAX Y N ❑Workers' alfirm thatl Insurance or a recteofdinpym msd(Sm.raor Lab C.)meofwhich FIXTURES-PER TRAP RECEIPTa Workers Compersation lrtsurenccon rectified copy thermflgec.3800,Lab C.)which PARK FEE YN x covers all employee's under this permit DIVISIO BUILDING N FEESDIVISIOGAS-EA.SYSTEM- INC.4 OUTLETS R Policy IF Company GAS-EA.SYSTEM-OVER 4(FA) PLANCHECK PEE ❑ Ccnified copy,,hereby famished. ❑ Cenilied copy is filed with the city inspection division. GRFASEANDUSTRL WASTE INTERCEPT OR GRADING FEE CERTIFICATE OF EXEMPTION PROM WORKERS' GREASETRAP SOILS FEB COMPENSATION INSURANCE (This ssclumimer not be completed ifthe permit is furans hundred dollars(SIM) SEWER-SANITARY-STORM EA.200PT. ENERGY FEE or less.) I minify that in he performance of the work for which this permit is issued,Isbell WATER HEATER WNENT/EL6CUR not employ any person in any munner as to become subject m the Workers' PAID Compensationluwaof Califrpdc Date so WATER SYSTEM/IREATING Dam Receipt# Q Z Applicant Z 0 NOTICE TO APPLICANT.if.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL: .Or become subject to the Work&s Compensation Provisions of the labor Cable,you must � > forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE Ow. Q CONSTRUCTION LENDING AGENCY SHISMIC FEE I hereby affithatthem is a construction tending agency for the performance of U Z rm : U O the work for which this permit is issued(Sec.309'/,Civ.CJ TOTALELECTRIC FEE I<INer's NatePLUMBING FEE <ndeA Address QTY. MECHANICAL PERMIT FEE - U I cem y that 1 have tend this application and stare that the above information is correct.lugremocomply with all city and county nNinunces and state laws mletingm PERMIT ISSUANCE MECHANICAL PER h N buildiagconstruc.lon,and hereby authorize representatives ofthis city to emu upon the CONSTRUCI'IONIAX U Z above-mentioned propenyfor inspection purposes. ALTER OR ADD TO MECH. (We)agree to save,indemnify end kap h Ire.#the City of Cupertino against Ifid,lities,judgm s.costs and<a sea whi tv nany way ac rue egmnatsaid City AIR HANDLING UNIT(TO 10,000 CF) onseque h ti is pc AIR HANDLING UNIT(OVER Io.IXp CFM) ign rein Applicari Contract ¢ EXHAUSTHOOD(WMUCI) PAID HAZARD US MATERIALS DISCLOSURE HEATING UNIT(TO 100.00D BTU) Dam Receipt Willtheappliescourf me building occupant store or handle hamrdous material ere defined by the Cupeni Municipal Code Chapter 9.12,eM Ne❑eahh and Safety tIFAl1NG UNIT(OVER 100,000 BTU) Ede,Section 25532(x)? VENTILATION FAN(SINGLE RESID) El Yea 11 No ISSUANCE EWI'. Will thcupplicant orfutumbuiliingoccupant useequipment ordevices which emir I BOILER-COMP QHPOR 100,0001TU) hazardous is,contaminants an defined by the Bay Area Air Quality Man igemem BOILER-COMP(OVER 10(l BTU) • District? ❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. ph P4 p 8 1 have and the hmardous materials requirements under Chapter 6.95 of the Y' Culifomia11eahh&Safety Code.Seniors25505,25533and25534. 1undemmu Net lionm ¢ must the building does not currently have a tenant,that it is my responsibility to notify the Py cap .of the nxiiii enwhich be met pdm m iemance of a Certificate of EC n 1 19, + Occupancy. e Owner or nation and agent Date TOTAL: ISSUED OFFICE