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26039 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO :6INI.-REECTRI. . PERMITNO. APPLICATION/PERMIT PLUMBING.MECHANICAL 26039 �` 0 O 9A BUILDING DIVISION BUILDING PROJECT IDP.N'I IFICATION `�+ 3 BUILDI G/AADDD_RESS: �/ , ' 1 SANITARY NO. APPLICATION SUBMfITAL DATE Us-a / sr 0 aj�/ N D UNIT 0 LOT N /N l-a OWNERSfJAME� PHpNf:: � COy{ACTO 'S NAME: l/ S�t>p�S OY NIC CONfROLp ARCHITECI'M'GINE LIC NO: AD CON'PACD PHONEQTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO BLDG ELECT psLuwl MECH PERMIT ISSUANCE 1:1 Ely�l El LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION CCZ I hereby affirmthat l am licensed under provisionsof Cheper9(wmmera:ing with ���fff I X00 Section 7000)of Division Sof he Business and Professions Cole,and my license is in PANELS �� �k• ©�' I . 1, full force unit GGIf t. _ S ' l�_l// O/ ` J 4Zc- License use Lic.N� UP T0200AMPS vFs,Q=y Date CommARCHITECTS lDr 201-1000AMPS / pp'I /�S .FT. [AEA $/SQ.FT. Z�NZ DF,CLARATION OVER IOOO AMPS y `'I /' \ O.1_a I understand my plans shall bo used as public records. J yFm SIGNS ELECTRICAL �. Y�J Licensed Professional ) VVV yI1I1Ly1p1 XO a U Inghereby affirm that I am exempt from the Contractors License Law for the /4J.U7C L{av' W 3 40`F¢/' following reason.(Section construct, Business crit Professions e,de o demolish, Code:Any city st county TEMP,ML-TER OR POLE INST. t e Et o J which requires a permit to construct,apli,improve,oh .it t,or repair any structure ad<0 that he s licensed pursuant requires theaisions of the Cbpermlun Lice signal sechmem POWER DEVICES W�as 0 that he is licensed p Sectio to the provial Division of he the Burin rs License law(Chapter SWIMMING POOL ELECTRIC d Xo� 9(commcncing with Section l0l%)of Division3af he Business and Profusions Code) VALUATION m_y or that he is exempt therefrom and the basis for the alleged exemption.Any violation of ppTLETS-SWITCHES-FlXTURES C/q}ye rya Section 7031.5 by any applicant for a permit subject'the applicant to a civil Penalty of t/V(f i=O notmoreflanfivehundrMdollars($500). NEWRESIDENTIALELECTR _SQ.FT. xt ❑ I,asownerolhepropeny.ormyemployceswih wages aztheirsole<ompewdon, STORIES 'TYPE CONSTRUCTION will do the work,and the somerom is not intendedoroffcred for.salc(Sec.9044,Business and Professions Coes:The Contractor's License law does not apply to an owner of proper,whoburldsorrmproves thereon and whodoessuch work hima Ifor through his own employees,provideddm,snch improvementsme no,rmeadedmaffemd forsale.If, OCC.GROUP RFS.UNITS It..,cr,the buildingnr improvement is old within enm year of completion,the owner- TOTAL: builder will have he burden of proving that he did not build or improve for purpose of sate.)' QTY. PLUMBINGTERMIT FEE FLOOD ZONE APN ❑ I,asnwnerofthe propeuy,em exclusively continued,with licensed contractors to onstrvct the project(Sec.7044,Business and Professions Code:)The Contractor's License law dcesnmepplyoan ewmerofproprey whobuildsor imrog pvesthereeand PERMIT ISSUANCE who contracts forsuch project with a conmeter(s)licensed pursuan,I.JaConlractm's Low. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY License ❑ I am exempt under Sce. ,B&P C for this moon OUTSIDE FEES BACK MOW PROTECT,DEVICE SANITARY Y-N - Owner Dam RCCEIPI'N � DRAINS-FLOOR,ROOF,AREA,COND. �Ihcaby affirm Oha IIM1 v havecertificate PellmnuON Jnt to sefmsurq or a certificate of FlXTURES-PER TRAP SCHOOLTAX Y N HI?CEIVI'p Workers'Compensation Insurance in acernified copy thereof(Sec.3800,lab CJ which PARK FEE Y N I ve"Nllc�ypq urvkrlys pcearn GAS-[iA.SYSTEM-]INC.4 OUTLETS RECISION Y-La Y S BUILDING DIVISION PEES Compony sT GAS-EA.SYSTIiM-OVER4(EA) PLANCHECK FEE ❑ Certifedcopyisherebyfumished. Ip/Certiried copy is riled with he city Inspection division. GREASEHNDUSTRL WASTE INTERCEPTOR GRADING FEE CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE COMPENSATION INSURANCE (This section need not bo completed lithe permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.201 ENERGY FEE orlessJ I crusty the in the Performance of he work for which this permit is ruucd.I shill 1 WATFRIIEATERW/VENUELECIR not employ any person in any manner to as to become subject to the Workers' PAID Compensation Lewsnf CaHfnnin. Date WAI'ERSYSTEMITREATING Dine RecciptN O z Applicant NOTICE.TO APPLICANT If.dor making this Certificaa of Exemption,you should NEW RESIDENTIAL PLMR. SQ.FT. TOTAL: tz+ becomesubjed to he Worker's Compensation provisions of he father Cod,you must 7 birhs,ith comply with such Provisions or his Permit shall he deemed revoked. BUILDING FEE H] F CONSTRUCTION LENDING AGENCY SEISMIC FEE t1 hereby affirm that there is a construction lending agency for the performance of U O the work for which hmi is pert is issuedec (S ,3091,Civ,C.) TOJAL ELECTRIC PEC WW Lrndei s Name u-' F Unde:a Address QTY, MECHANICAL PERMIT FEE PLUMBING FEE V 1 certify that I have read his application and sma that he above information is MSCI IANICAL FEE >- correct. Iegtatocomply WithallchyandcountyoNinaneeaandsateluwsreletingto PERMIT ISSUANCE building construction,and hereby auhonse mprucnadvesofthisesty to enter upon the CONSTRUCfIONTAX Q) Z uhove-mentioned propcuy far inspection purist ALTER OR ADD TO MECIL We)agree to.save,indemnify and kcep harmleas the City of Cupertino against timiliuesjidgment.costandexpenses which may in any way ec<me gd I Cit AIR HANDLING UNIT(TO Ir"CFM) snc arace ocha,anti r this rmit ,tea 4 ✓( AIR HANDLING UNIT(OVER 10Jr CFM) ignaareof Ap n Contractor Date EXHAUSTHOOD(W/DUCn PAID HAZARDOUS MAI'I?RIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam Receipt if Will he applicant or future building oecoprm sem or handle haaardous mmerivl TOTAL: (OVER IW.OoO BTU) as definby the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT( ed Crile,Section 25532(x)? VENTILATION I-AN(SINGLE,RESID) 11 Yes ❑No BOILER-COMP(3HP OR 100.000 BTU) ISSUANCE.DATE Will theaPPlicmtorfuturcbuileingoscupam useequipmenl ordevices whicnrmh p InVannus air contaminants is defined by he Buy Area Au QuaEly Management BOILER-COMP(OVER 100,000 nn A RTU) r Dianctl ❑Yes ❑No NEW RISIDENTIAL MECH. SQ.PT. I have read he hemtdous materials requirenants under Chapter 695 of the (NAR 10 1994 California Health&Safety Code,Sections 25505,25533 and 25534.1 undersand that if the building does not comedy have a tenant that it is my a spunaibility to notify the - cupan of he can tremens which moo he met prior to issuance ora Certificate of CITY OF uurr al 111V Occupancy. Owner or auhonsed agent Date TOTAL: ISSUED BY: