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26050 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OFCUPERTINO 11 IL01 G-hILRLT.1 AL PERNM NO. n [� ark APPLICATION/PERMIT PLUMBING-MECHANICAL 2 6 O 5 O BUILDING DIVISION BUILDING PROJECT'IDENTIFICATION BUILDING ADDRESS: SANITARY NO. APPLICAT'IOONNSUBMIT ALDATE WNERS AVEN :. PHONE: CONTRACTOR S NAME: LIC NO: 1• NAC COMROLN ARCIIITfiCT/ENGI G R: LIC NO: A DRESS: r�M c. El I . CONTACT: PHONE: BUILDING PERMIT INFO QTY. ELECTRIC PERMIT FEE n-,�& PERMIT ISSUANCE BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDEN IAL OCZ TOB DESCRIPTION I hereby affirm that l am licenced underprovisions of Chapler9(commencingwith y�D�Q Ov0.i f Dii3l'thBid Professions Ca.end my licemcis in PANELS rumieixZF � UPT020 0AMP j icc Dam Comtnnor 201-I(NIO AMPS F'yZ A CHITECPS DEC A SQ.FT.FLOOR AREA $ISQ.FT. ZOr�— OVER 100(1 AMPS I understand my plans shall housed as Public beard, ^ �yF� SIGNS ELECTRICAL'� III I \ I �` Ir Q CQ Licensed Professional OWNER-BUILDER DECLARATION SPECIAL CIRCUIT SC.' iaf Oa p. I hereby affirm that I um exempt from the Contractor's License Law for Ne W3W, blowing muson.(Section)031.5.Businass and Professions Codes Any city ar county TI?MP.METER OR POLE INST. F W O< which rcyuircs a permit to consma,aimprove, emo ,or mpuiry st lter,ive,dlishanructure Y� prior m its issuance,also requires the applicant for such Permit file a signed statement POWER DEVI Fs DATE W Op that he is licensed,utsuant to the provision come Contractor's License Laos(Chapter - °'KCD,, 9(commencingwith Section 700(h of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC -_J VALUATION yt�rn mind he is Cxempt metemonand the hasisforthe allegediumannion.Anyvioletion of OUTLETS-SWRCH[S-FlXTURFS C O ©. ZaSection?03IS by any applicant for a permit subjects the applicantto a civil Penalty of _j G trn mom than Eve hundrW Aollurs(E51X11� NEW RESIDENTIAL ELIiCB _SQ.FT. STORIES 'TYPE CONSTRUCTION W F-o ❑ I.asnwnerofthepmprty.mmyemployaswilhwagesmtheirsolecompcnsatim, n:L willdo the work,and the xructure isnot imendedor offered for sale(Sm.V0oft Business :mJ Prnlb.asions Cash:no Comracmra License Law does not apply to an owner of progeny whomilds or Improves lherum,and whodres such workhimselforthrough his cmplmyees,providecidensuch impmvcttenbare not imm�dMmoffertd fonele.IL OCC GROUP RLS UNITS however,the building or improvement is sold within one yearofcompletion,the owner- TOTAL: milder will Lave the Normal proving thin he did not build or impose for purpose of `ale')' QTY. PLUMBING PERMIT I•LE FLOOD LONE MIN Luowneroftheprnpeny, mexclusivelycontraclingwilhlicensedcmmetomto Lrnsmer the project(Sea]044,Bushes;and Professions Cooll The Cominuou's PERMIT ISSUANCE pv icense Lowdoesnm apply mnnawimot uped,wh,mildsnrimProves 0ercnndmd J whocotnracts her such projects with aconmcardid licensed pursuant to the Contractors ALTER-DRAIN&VEST-WATER(EA) FEE SUMMARY License Law. ❑ 1 nm exempt malar Scc. .B&P C for this reusonBACK PLOW PRO'f1iC1'.DEVICE O .IDE FEES SANITARY YN Owner Date DRAINS-FLUOR,ROOF.AREA,COND. RECEIMa WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN EIIhemny affirm Nat(nave ecertiEcae of amsent n�:elf-insure,ora cenilicale of FIXTURES-PER TRAP BF.CEIPTp Works all em p<yaationlnu1his pemiLriates,ro to cnificd capY thereof(Sec.3tl00.Lid,CJ which GAS-FA.SYSTEM.)INC.40UTLETS PARK FIiIi YN p mm RECEIPI'N coverPolicy p s�n er BUILDING DIVISION FEES Company Q +Z (1 '1� GAS-EA.SYSTEM-OVER4(EA) PLANCHECK FEB ❑ Certified copy is hereby furnished. IF,Ccttilied copy is filed with the city inspection division. GREASMNDUSTRL WASTE INTERCEPTOR GRADING FEE CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS rEr COMPENSATION INSURANCE f1'his section need not he compered lithe permit is for one hundred do1lars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE unless.) I cenify that in the perfotmmtc<ufthe work fm which this,emit is issued,Ishan WATER HFATFR W/VENT/GLECfR •,$ not employ nny parson In any mummeru as m become subject to the Workers' PAID Compensation lsws of Calilitmia. Dams WAF,R SYSTEM/IRHATING Date ReceiptN O zApPlir t O NOTICETO APPLICANT:If,after making this Cerlifcme of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL: 0 become subject nothe Worker's Compensation provisions of the Labe Cade,you must � > forthwith comply with such provisions m this permit shall be obscured mvoked. BUILDING FEE L17 [) CONSTRUCTION LENDING AGENCY SEISMIC FEE z I herchyaffrtm lhatlbem iso annstuarim lending agency fon he performance of TOTAL: �ryI ELECTRIC FEE U Q m the work for which this is issued(Sec.3097,Civ.C.) i• lender's Name PLUMBING MEG u" F Lenders Address QTY. MECHANICAL PERMIT FEE U I certify that I have read this application and sum that Ne above information is MECHANICAL FEE correct.l agree to comply with all city and county oubmancea and state laws relating to PERMIT ISSUANCE building construction.and hereby aothorim representatives of this city to enter upon the CONS'IRUCfION TAX U z above-menllonedproperty for inspection purposes. ALTER OR ADD TO MECH. (WC)agree to save,indemnify and keep harmless the City of Cupertino again liabilities,judgmems.costs undexpeores which may in any way aceruaagaint said City AIR HANDLING UNIT TO 10.000 Cl ttsulucncc nlife ming. fi momt. y AIR HANDLING UNI'1'(OVER 10,000 CPM) gnure of Applicam/Commctor 'Date EXHAUST HOOD(W/DUCry PAID w HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 10Y"BTU) Date R...a N Will the applicant or future building Occupant stere or handle Institutions mammal HEATING UNIT(OVER 103.000 BTU) �• us defined by the Cupenim Municipal Code.Chapter 9.12,and the Heath and Safety TOTAL: S-0 Cade.Section 25532(a)? VIe 1LATION FAN(SINGLE REBID) ❑Yes ❑No ISSUANCE DATE Will thea licanmrfumre buildin fusee ui mertmrdeviceswhichemit BOILER-COMP CUP OR Bit"BTU) pp l by then 4 P Incursions air<omatrtinana u defined by the Bay Area Air Quality Mvugetrtem BOILER-COMP(OVER 1IXI,W0 BTU) P ,A IID District? ❑Yes 0 N NLW RESIUENTIAI.MECH. SQ.FT. I have mad the baaud m;mmerials mgairemenu under Chapter 6.95 of the FEB — 9 1994 CaRfomiu Health&Safety Code,Sections 25505,25533 and 25534. 1 understand thio if the building does not currently have a tenant,that it is my responsibility to notify the occupant of the requ ircomms which most he out prior m issuance of a Caradmite of CI I�' Ur GUYr H rvr Occupancy. Owner ser nuthorieed agent Date TOTAL: ISSUED BY: OFFICE