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24491 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINOB ILD{ G-ELEC'I'RICA]. PERMTTNO, BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL n /I /I WILDING PROJECT IDEN'T'IFICA'T'ION L 4 !•� 91 BUILDING�ADDRESS: T SANIARY NO. APPLICATION SUBMITTAL DATE MRI TT `OR UNIT# LOTH OWN' AME: P IONI^ CON'T'RA R'S NAME: LI NO: C OM �UdNU 52 7bb q �n� NIC CON ROL# ARCHITEC/LNGINIiER: LIC NO', ADDRE'S' (� 1 • 4hF 51 J 2— CONTACT. CONTACT. ry PHONE: Q1 Y. ELECTRIC PERMIT FEE BUILDING PERMIT INFO �i no" B- _ k \ _+� /T(\11{—WBO BLDG [Eruct' - PI MF.CH 1 1 /F{YRJ-�-{LIs G. LNIkMS L•l Okay PERMD'ISSUANCG i El El LICENSED CONTRACTOR'S DECLARATION APPLIANC[3-R131DENTIAI. TOB DESCRIPTION OCL Ihereby.ffirmision thin I 3 idflnsedunss ddfiofisi...Codr9nd(commencing se with _w . 00 Section 7000)of Division J of the Business anti Professions Code,and my license is in PANELS 1Jfi-(vim`-`J NN/1 y�F full force and if eV — FZW Liccnf lac, Lic.# UPT0200AMPS vs?y Doc 1 {.—=o Comrcclo — InLT 201-1000 AMPS SQ.FT.FLOOR AREA 1"tn Z_ ARCIIITF.CTS DECLARATION OVER TWO AMPS ZO°s OZ I understand my plans shall be used as public records. FyF W SIGNS EhECIRICAI, Q Y W J Licensed Professional � thep�Q OWNER-BUILDERCi DECLARATION SPI:CTAT.CIRCUIT/MISC. XI hereby am exempt ffirthat I nm efrom me Contractors License Law for the m30< following to con L5,Business and profusions Code:Any city mcountyacture TBMP.ML'fliR OR POLE INST. © I N O Q which requires a permit to constrvcl,ager,improve,demmlisM1,or repair any structure cc..2 prior to is issuance,also requires the applicant for such permit to rile a signed statement POWER GENICCS 1 ,W<0 that he is Eventual possums to the provisions of the footman's License Law(Chapter SWIMMING POOL ELECTRIC dEaW 9(commencingwidn Section 7000)of Division 3 ofine Businessman Professions Cude) ALU TION mw _ onhat he is exempt mertfromnnd the basis 6r me alleged exemption.Any violation of /� F_Z¢ Section 7031.5 by any applicant for m permit subject the applicant OUTLETS-SWITCIIfS-Fl%TURUS o a civil penally of I� pl not more than five hundred dollars($500). O NEW RESIDENTIAL ELECIH S TYPF.CONSTRUCDON mF� ❑ 1,esownerofinepropny,ormycmployccs wimwagesestheirulecompcn..tion. T a3:L will dome work,andthe structure isnot intended coffered for sale(See7044,Business and Profusions Codc:The Contractor's Liceme Law dies nm apply m an owner of propcnywhoboilds orimproves themon.andwhodoessuch work himulfnrthroughhis cmployecs,provided that such improvcmenaareno intendedoroffered formic.If, OCC.GROUP RFS.UNITS however.the buildingor improvement is sold within one year ofcompletion,theowner. TOTAL: builder will have the burden of proving that he did not build or improve for purpose of 'S81PLUMBING PERMIT FEF, ❑ I,asowner of me progeny,mnexdusivdycomracting with cedmrummQTY.licenco o FLOOD ZONE APN construct the project(Sec.7644.Business and Professions Code:)The Convectors License Lawdoes not applym anowncrofpmpny who builds or improvesthemon,and PERMIT ISSUANCE whocommcu frrmch projects with acontrusums)licensed pursuanunthe Contracmrs ALTER-DRAIN&VENT-WATER EA) FEE SUMMARY License Law. ❑ 1 am exempt under Sec. ,B&P C for this reason OUTSIDE FEES BACK FLOW PROTECT.DEVICE SANITARY Y N Owner Date DRAINS-FLOOR.ROOF.AREA,COND. RECEIPT# WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N �9(/Ithereby affirm that l have a modicum ofemmennn selfimim,or a certificate of FIKTURUS-PER TRAP RECEIPT# Fokus'Compensation Insurance acemFel copy thercof(Sea.3800,Lab C.)which PARK FEE Y N owmaull plc N LECEIPT# nIYpT.�ti T GAS-IiA.SYSTEM- INC.INC40UTLETS BUILDING DIVISION FEES Policy# 's'yla- any El Cee GAS-EA.SYSTEM-OVER 4(IiA) PLANCHECK FEE ❑ Certified copy is tied theriJ. Certified copy is Bled with the city inspection division. GRGASIpINDUS'IEL WASTE,INTERCEPTOR GRADING FEE CERTIFICATE:OF FXEMPION FROM WORKERSGREASE[RAP SOILS FEE COMPENSA'I'[ON INSURANCE ("flus section need not la,completed ifthe peril is formic hwtdnal dollars lS l 001 SEWER-SANITARY-STORM EA.2(X)17. ENERGY NE talcs.,,) I certify that in the imformmccofthe wick for which his permit is issued,l shall WATER REA'I HR W/VENT/F;IUCTR not employ any person In any manner so as in boeome subject In the Workers PAID Cnmpensmian Laws of Culi¢smiu. Doc WA'1'E:R SYS'I'EM(1'RHAI'ING Date Receipt# O z AppLaam z � NO]ICF TOAPPLICANT:If,ofrermakinglM1i.CmdrilumofExemption,you should N17W RESIDENI Al,PLMB. SQ.IIT. TOTAL: q] bccomcsubject to the Worker's Compcmmian provisions of t he],.No Code,youmusl odhwilh comply with such im,,sams m this peril shot l be deemed revoked. BUILDING FEE W r� CONST RUCTION[.ENDING AGENCY - SEISMIC FEE z I hereby affirm that there is a construction lending agency for the performance of U O the work for which this peril is issued(Sec.3007,Civ.C.) TOTAL: ELECTRIC FEE Lender's Name PLUMHINOFEE [2. F lander.,Address QTY. MECHANICAL PERMIT FEE O U Iccimfy that 1 have rend his appLcalion and tame mat me move informants-,is MECHANICAL YEP. correct.l agree to comply with all city and county andmancesendomc hos,m1min,1. PERMIT ISSUANCE 0,1 building construction,and hereby mahorim representatives oflhis city in enter upon the CONSTRUCTION TAX LI ,Z above-memioned progeny for inspection purposes, ALTER OR ADD TO MIKE. (We)-gree m,mr ,indemnify and keep hart...the City of Cupcninu.,.fast rnrn Iiabilities.judgmems,costs and expenses which may in any way accrue againstsaidCity AIR HANDLING UNIT(TO 10,00)CFM) W io ppn the dgwningofmr inpeil. D \x11 stance AIR HANDLING UNIT(OVER I0.0W CPM) A- I I )a_ tram rent Appanom licVCmm cr Oa EXHAUST HOOD(W/DUCT) PAID HAZARDOUS MATERIALS DISCLOSURE: HEATING UNIT(TO 100,00X1 BTU) DaI t p Will the applicant or future building occupant store or handle hacudous material as defined by the Cupertino Municipal Codc.Chapter 9.12,and the Ilcahh and Safety HEATING ONI'I'(OVER 100,000 BTU) Cod,Section 2553200?v VENTILATION PAN(SINGLE BESIDE❑res qQ Nn ISSUANCE DATE �i BOILER-COMP(3111 OR 100,tID0 BTU)) Willthc applicanmr future buildingoccupantuu cquipmcnmrdevices which emit (" havarrh us air conaran¢ minas defined by the Buy Am.Air Quality Management BOILER-COMP(OVER 100,0(X0 BTU) Disuict7 ❑Yes XN. NEW RESIDENTIAL MECH. SQ.FT. 1 have read me horafdous materials resiuimmans under Chapter 6.95 of the NOV2 4 ,gni California Health&Safety Code,Sections 2.5505.25533 and 25534. 1 undersand 1.1 if the building docs not currently have a moral,than it is my responsibility to notify he (GI I yy of--11�;fo it , acJ(, e o the r to -nemsu s which mum be met prior to issuance 7f a Cert'¢me of V h s IttwE r authomed agent Dam FF_ TOTAL: _ ISSUED BY: OFFICE