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24638 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINOBUILDING-ELEC'I'RICAI. I'IiRMIT NO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL n �I C �e BUILDING I'ItO.IECT IDN:N'1'II+(CATION L 4 v o BUILDING AADDDRRI3IISS: SANITARY NO. APPLICATION SUBMITTAL DATE /�I .�\w�aAs1Q \ UNI'1'p LOT# OWNh`V V PI I(IN'' CON'I'RACfOR'S NAME: LIT.NO: v NI OL# \�NE N/C CONTROL# ARC]HTECn/ENGENEER: LIC NO: ADDRISS: ❑ CONTACT: PHONE: v BUILDING PERMIT'INFO Q'I'Y, ELECTRIC PERMIT' FF.A BLDG ELECT PLUMB MECH PERMIT ISSUANCE El ❑ LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL Oyz II...ebyaffoml had lam l leenacdranderpnrvision,of Chupter9(rommencin"Oh JOB DISCRIPf[ON WOO Section 7000)of Division 3o fine Broma,as and Pmfeasions CMe,and my license is in PANELS �i 1 F< full License Class ellen. FS Lk g WU License Class Lic.p UP TO 200 AMPS m]oo Date C.nroemr 2011-ION)AMPS Z F,z ARCHIJ ECT'S DECLARATION OVER I(NIIlAMlS SQ.FT.FLOOR AREA S/SQ.Ff. 0 z—0 I understood my plans shall he used as public words. <rn'[W SIGNS ELECTRICAL © A l 6yfJ Licensed Professional �V Ly�< OWNER-HUB.DER DECLARATION SPECIAL CIRCUEUMISC. _ OI, I beach, from That I mn exempl from Jin Conlmdm'a Libman mLaw Iia he Q W3h-tFir following reaa .(Senion]031.5,liusine>s and l'rufcomm.Code:Any city or manly TEMP.METIER OR POLE INS'1. I 1 ' ` J_Oo< which returns,a permit In contract.alter,improve,demolish,or repair any structure KW}� prior to its issuance,also requires the applicant for such Permit o file a signed statement POWER DEVICES y1p4<0 that he is licensed......at to thepmvist...ofthe C.ntrun.rs License law(Chincr W � 9(m.nmencingwishSeclioo7000 of Division 3 of the Bnaineea and Probsoma,Code) SWIMMING I'OOLIELECIRIC eVAIUA _m or that he is exempt therefrom and the basis for the alleged exnmpolon.Any violation of pUTLF.TS-SWITCHES-FIXTURES �zY Section]031.5 by any applicant far a permit subjects the applicantto o civil penalty.( not more than Eve hundred dollars(5500). NEW RFSIpfNTIAL[LECTR S FT. ,�j ❑ I,avtwnerophe property,ormyemployeea with wages avheinnlecompenmtion, Q' STORIES TYPE CONSTRUCTION y3� wl11 do@¢work,anti the strucwm is agintendetl or ol'rared for sule(See,7044,Boomers and Ihnfeasions Gde:'Pat Comntelm,License Law does not apply to an owner of property who buil.).,.,improvesthereon,and whodtes..th work himself.,thrmgh his own employees,provided that such improvements..not intended ondferedforaale.If OCCGROUP RFS.UNITS however,the building or improvement is sold within oneyear of completion,the owner- TOTAL: bulkier will have the burden of proving(bat he did not hand 0r Improve for prop nt,of aide.). ❑ I,as uwmer.fthe property,ame,cduaivelyc.ntracling with licensed contmctnrs m QTY, PLUMBING PERMIT' FEE It.00p ZONE APN Lmonsact the project(Sec.]044,Business and Profession,Code,The Contractor's i icense Lawdces not apply to an owner,rproperty who build,or improves theman,.na rEiRMIT ISSUANCE who comm,,,forsueh pntjccta with aaanaaaor(s)licensed parsunnl to the Commemr's Is License I.a.. ALTER (IN FEE SUMMARY ❑ I am exempt undcrSec. ,B&P C for this myon BACK FLOW PROTECT.DEVICE TSIDES SANITARY Y_N Owner Dam• pRNNS-FLOOR,ROOF,AREA,CONK RECEIPT#WORKMAN COMI'IENSA'I'ION DECIARAT'ION SCHOOL Y_N ❑ Ihemby alfrm lhmlh.veacerlilicam ofennsdm to selI,...re,macenifeamaf RECEIFI'# Worker%Compeneadion Insurance oracerified ropy thereof(See.3800,Lob C.)which PIXTURI3-PER TRAP PARK ITE Y N covers employee's under this permit. AS-FA.SYSTEM-1 INC. OUTLE-1 S RECEIPTp Policy# M �a BUILDING DIVISION FRIES Company ❑ Cenertifcd copy is bdrehy tarnished. GAS-FA.SYSTEM-OVER4(EA) PLANCHEUK FEF, ❑ Certified copy is filed with the city insPenion division. GREASEIINDUSTRL WASTE INTERCEPTOR GRADING FETE CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE COMPENSATION INSURANCE (I Insseetion need nod bewntpinedifthepermh is roronchundneddoll.Ship) SEWER-SANITARY-STORM F.A.200Fd'. (ENERGY PHIS or less.) Iccrify that in the performanm ofthe work for which his permit is issued,l shall WATER 1111nTER W/VFNI'AEECD4 not employ any person in any m as m become subject to the Workeri PAID Compenemion Lawsnr Cal'Ifomia.manner so WATER SYSTEM/TREATING [)are Receipdp z Applicant 2 6 NOTICE TO APPLICANT:lCithermuking this Ccamficutc of liscatighn,you should NEW RESIDENTIAL PLAN. SQ,FT. IDEAL: batorm,subjecnodhe Worker,Compensation pmvisiovortne tabor Code,mi est > forthwith comply with such provisions or this permit shall bo deemed revoked. BUILDING FEE 6Wi Q CONSTRUC'T'ION LENDING AGENCY SHISMIC FETE z Ihcrchy affirntlun Nene iso ronsvunion landingagency far the pcafonmmc.of �� U O the work for which'his Permit is issued(Sec.3097.Civ.C.) T AL: ELECTRIC(BEE kl. r Lender's Name 1-' Leader's Address - QT'Y. MIiCHANICAL PGRMIT FEE PLUMBING EEE V T cemrif,ry that have rcaJ this application and erode that the xMwe infonnminn is MECHANICAL.FEE build,. ommormcnmply with ell butane d,pmcynMinea.f and chirn,wamlming a PERMITISSUANCC 1" Z batee-gcon,mni.mmJhereby n,unnsnim.preasea. dives.Ithiscity.¢merupon the CONSTRUCT ION TAX (� z aboveWe)agred pmpvnyforinapenind keepahes. ALTER OR ADD TO M[Cfl. (We)agree 1.save,indemnify nlld keep mayhicrale.,the City,o Cuperin.against Iiaemasoinanngmenh,dn,(svtd which may many way accrue ugainxtaniA City AIR IIANDLINO UNIT p'0111,IIINI CFM) ZDATE in nseyurnce of(he graining of tis permit. Z1 -LAIR HANDLING UNIT(OVER IB.ODOCFM) gignnm )f Apid cant/C.ntm,or �/ Date EXHAUST 11001)(W/DUCT) rnmIIALANDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date ReWill the applicant or future building occupant store or handle hazardous material ❑tiATING UNIT(OVER IBB,(pO BTU)as defined by the CuNitino Municipal Code,Chapter 9.12,and the IIcahn and SafetyCode,Seninn 25532O0PVIiNTILA'1ION PAN(SINGLE RESIDE ❑Yes ❑NoWill Iain concainor is ar building by the lusoequipmentorality anagement [5BOILER-COMP(3HP OR 100,0X0 BI'U) ISSUANC hazaMom air contaminants az defined by the Buy Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) A Disvim'1 ❑Yes ❑No NEWRESIDIEN'UALMECIL SQ.P,n a� I have read the bacWna,mamniads"pirconenta under Chapter 695 of the IMI Health EC 22 19912 California ealth&Safety Code,Sections 25505,M533 and 25534. 1 understand that if the building does not currently have a tenant,that it is my responsibility to nmify the wupunt of the regnlren mats which most N,m,prior to notational it Cenifibam o1' r VF LU�rCC1.I II B V V Occupancy. V t/�� • 1 Owner nruwhonzed agent pate TOTAL: ISSUED BY: OFFICE