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26923APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY CITY OF CUPERTINOBTm1.IN'11 - ELECTRTCAI. APPLICATION/PERMIT PLUMBING - MECIIANTCAU BUILDING DIVISION BUILDING PROJECT IDENTIFICATION PERMITNO, ] C n <� G V G J 26923 BUILDING ADDRESS : SANITARY NO. SSUUBMITTTAi LL /✓/1 / 6 �J� f 4- /LGP UNIT. LOT ,LDRII /APPPPPLICA'HOONN a/��(� V' _ O ERS NAME: PHONE: P a CO TRACTOR'S N 1G LI NO: & y NIC ❑ CON IKOI.a 'ARCI{I 'I!C'I'/ENGINHER: LIC NO: AU iss: L CONTACT: PHONE QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO BLDG ELECT PLU��IfB MECH PERMIT ISSUANCE 11El LICENSRD CONTRACT' OR'S DECLARATION I herby affirm that l am licensed underprevisionsuf Chaper9 (commencing with APPLIANCES- RESIDENTIAL TOB DE ON J Stereo 7") of Division3nf the Business end Professions Code, and mylicenu is in — full Tome and dfec LLiceneti Lic.N� `� o Date Commaor pprypUS UP T0200 AMPS ' - - 1IO AMPS ARCHITECTS DIi ARATION � 1 unJcrsbnd my plans sM1a11 be used us public records. OVER 1000 AMPS OVER SQ IT. FLOOR A ' $/SQ.IT. SIGNS ELECTRICAL I' NO\VII 1 J License] Rafcssionnl OWNER -BUILDER DECLARATION I hereby affirm oar I am exempt from the Comractnr's License Law for the o fallowing reason. (Section 7031.5, Business and Professions Code: Any city or county which requires a permit m,momw, ,slur, improve, demolish, or repair any suumum SPECIAL CIRCUIT/MISC. TEMP. METER OR POUR INST, n n _ C prior to its issuance. also requires the applicant for such permit to file a signed statement POWERDEVICFS r r^^ j that he is licensed pursuant to provisions of the Contrecmre License Law(Chapter 4 9(commencing with Section700B) of Division 3 ofthe Business and Professions Cade) or that he is eaempuherefmmand he basis for the alleged exemption. Any violation of Section ]1131.5 by any applicom for a mm, subjects the applicant as a civil penalty of not mac than five hundred dollars ($500). ❑ I, asowneroOhe n prapc y,orm e I 1 1 SWIMMING POOL ELECTRIC \ A ^ ALIIATIO STORIES TYPE CONSTRUCTION OUTLETS - SWITCHES - FIXTURES — NEWRESIDEb7IALELECfR _ Q.IT. 044. Busmen, o will dothework, and theruucmmis not Liflense awdofarsale (Sec. of onceyedorofemd for sale Easiness and Prlywhions to sm Contractors License Law does not apply m nn owner iof ldsminm. s progeny who hulldsorlmnnrvce thereon, and whndnes such work him;elfor lhroughhf, m;,provi far ownever, msorcneyear OCC GROUP RES. UNITS h or improvementsold fcompffemd howeer, will avec a burden efrmem issoldhe id noney<ar of improve foron, the owntt- owneL builder will have mite burden of proving that he did not build or improve for purpose of TO.I.AL QTY. PLUMBING PERMIT FEE sale.). ❑ Las owner ofthe property, am exclusively contracting with deensea ormmmors n . FLOOD ZONE APN consumer lbs project (Sum. 7(W, Business and Profession; Code) The Comment's License Lawdes, nompplymmmowne,id prnpcny whobuildsorimprovee throven.anJ PERMIT ISSUANCE �. whacerawero for such projects with a comrecoods) licensed pursaam to the Contractor; License Law. ACIER-DRAIN@VFM-WATER EA ( ) PIiE SUMMARY ❑ I am exempt under Sec. , B & P C for this reason BACK FLOW PROTECT. DEVICEISTD E. '1'ARY Owner DRAINS- FLOOR, ROOF, ARIA, CONE. FIXTURES PER TRAP SAN] Y N RI?CEIPI'q WORKMAN COMPENSATION DECLARATATION ❑ Thereby affirm thus lhuveerenificam ofrnuscm mulLins...... cenificmeof Workers'Compensation has ... to ora cerificicopythereof(Sce. 3800, Loh C.) which versull coma Policy. /SOdi SCHOOL TAX Y N PARK PARK FEE Y N RIiCEIPTIt INCAOUTLS GAS- EA. SYSTEM -1 ET BUILDING DIVISION FEES Com TT GAS - EA. SYS'T'EM -OVER 4 RA) PLANCHIiCK FEE Ceeilied ropy is hereby fumisM1ed. ID Cen Cenificd copy is filed aid, the city impwtion division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING IEE CERTIFICATE OFEXEMPUON FROM WORKERS' COMPENSA9'ION INSURANCE GREASETRAP SOILS PIIS SEWER - SANITARY - STORM HA. 200FT. ENERGY PER .(Ihkatelon need not he completed if the permit is for one hundred dollars ($100) or less.) tum T EA'TvR W/VENT/T:LECIR I certify that in the performance ofmite work for which Ni; permit is issued,(shill not employ any person in any member so as to become subject to the Worker CompensmionJ.awsof Cnlifomie. Data AppLcnnt WATE STER TREATING PAID Data Rece' t q NOTICE 10 APPLICANT. ILafer making this Cenifcme of Exemption, you should become subject to he Wmkc/s Compensation movisioo.fthe Lobar Code. you most IFIRESIDENTIAL PLMB. SQ. M'. TOTAL: forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING PER CONSTRUCTION LENDING AGENCY SEISMIC FEE I hereby affirm that hem is a construction lending agency for the permarmocc of ,be work far which this permit Is hatted (Sec. 3097, Civ. C) Lenders Name TO - 'A F.LECI 'RI - Leaders Address QTY, MECHANICALPERMIT FEE PLUMB G I certify that 1 have mad this application and state that the above information is ,PERMIT ISSUANCE MECHANICALFE correct. l agree to comply with all city and county ordinances and stare laws relating to building consomelion, road hereby someone repmandidves of this city to enter upon the above-mendoneJ n far inspection purposes, props y eposen ALTER OR ADU'I'O MECI{. CO'S 110 AX (We) ogre to save, indemnifyandkeep harmless the City Cupertino against 4— liabilities,judgmen is nndexpenses which may loony way accrue aguimt said City r AIR HANDLING UNI'1'(TO I(I,IXq CFM) I con gnenc the granting tti perms. AIR HANDLING UNIT (OVER I(hOW CFM) X/s L^/ a / , Ii � V � RLI Na Sigeto.W. �erano//Ca�nlnR4or Date I HxI IAOST HOOD(W/DULT) PAID HEATING UNIT (TO 10000 BTU) HAZARDOUS MATERIALS DISCLOSURE ate Receipt. Will the applicant or future building occupant store or handle hazardous material as defined by the Considine Municipal Code, Chapter 9.12, and the Health and Safety ❑EATING UNI'1'(OVER 100,000 BTU) 'q . Godo, $cclimn 25532(;)1 ❑ Yea No ❑ VFNTILKTION PAN (SINGLE RESID) Will the nroura m ar building use ordevices which emit BOILER - COMP (31If OR 100.0i BTU) SUANCE DATE t, as by he hazardous air contaminants as defined by the Bay Area Air Quality Munagintent Area Ali DisViclP "1 p , HOLLER - COME' (OVER 100,000 BTU) _ ❑ Yce No 11V T� M NEW RESIDENTIAL. MUCH. SQ. I.I. 1 have read the hazardous materials requirements under Chapter 6.95 of the •• 1994 California l lcallh & Safety Code, Sections 25505, 25533 and 25534. l understand that J Am __ if the building does not currently have a tenant, thus it is my responsibility to notify the occupant of the requirements which must he net prior to isauunce ora Ceni Note of Occupancy. CITY U� iJ IN CIi I INN ISSUED BY; Owner m awhor msi agent Date TOTAL: OFFICE