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24521APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY CITY OFCUPERTINO 821-)1hr-KLECI'R1 AI, APPLICATION/PERMIT PLUMIIING-MECHANICAL. , HULLOING DIVISION IIUIhDING PROJECT IDENTIFICATION PERMITNO. /� a� [� Lc BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAIT Z r UNITp OT J \ JA k y�� OWNERS NAM — PHONE: CONTRA H'S NAME: aLIC NO: ••VPa���l/l N& ❑ CON TROI.q CHI ;CI'/.NGINEIiR: LIC ADDRESS: CONTACT: PHONE: QTY, ELECTRIC PERMIT FEE BUILDING PIiRMIT INFO BLUG ELECT P UMB MECII PERMITISSUANCE El ❑ El LICENSED CONTRACTOR'S DECLARATION I herehyaffirmtha I am licensed under provisionsofam wer 9 (commencing with APPLIANCES - RESIDHNTIN. TOB DESCRIPTION Section 7000) of Division Sof the Ismincasand Professions Clde,andmylicer isin PANELS full fou and effect. 1 License Class Lic.p UPT02MAMPS � Date Compactor 201 - IMill AMPS ARCHITECTS DECLARATION I understand my plans shall b, used as public records. OVER IBM ANTS SQ. PI'. FLOOR ARIA ERQ. IT. SIGNS HLECTRICAL Licensed Professional i OWNER -BUILDER DECLARA'I ION SPECIAL CIRCUITIMISC. I hereby affil that I sat exempt from the Contractors License law for the fallowing .... (Section 7031.5, Business and Pmfcssinrn Code:Anyc4,mcoumy © ra I`VE TEMP. METER OR POLL INST. which requires a petit as construct, alter, Improve, demolish, m repair any structure ., ,. prior to its iwronce,aEnm... . reatbcit,icaniforauch permit to file aligned statement POWER DEVICES that he is licensed purstontlothe ponswooeof the Contractor's License Lave (Chapter 9(commencing with Section Tl00)mf Division3ofrhe Business and Professions Code) A.0 PION SWIMMING POOL ELECTRIC or that he is exempttherefrom and Ne basis for alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of /43 OUTLETS -SWITCHES -FIXTURES fie hundrllare (NF.W to eryyeinpinyceswithwagesustheirsolecompensation, RIiSID13M IALIA.IiCTR _kSQFf.tw STORIESnATE PI?CONS'I'RUCI'ION cwork. and the emeture is not intended orriffereJ forsale(Sm 7014, Business r�7�11�.Illoaqcew.pmvidrd eoione CnJaThe Crummemea License law Does not apply to am owner ofwho btildsmimprovestheron, and w1mcksmsuch workhimselfonhmughhisOCC thatsuch improvemenuas, not imendedorofrered forsale. If, GROUP RES. UNITS 1 OI AI"' however, the building or improvement is sold within one year ofcompletiun, the owner builder will have the burden of proving that he did not build or improve lin purpose of QTY. PLUMBING PERMIT FEE le.). ❑ I, as ownerofNe property.amexclusively contracting with licenses! contractors to 11-OOD ZONE APN cons Wet the Project (See IM,1, Business and Professions Code:)Th, Contractors License Lawdoes nmapplyto an mwnerof pmpedy who huildsor improves thereon.and PERMITISSUANCE / who cmnnmts lorsuch projects with a cont owlmbd licensed pumuad nm the Cmnnsetorr License law. ALTER-DRAIN&VI?N'r-WATER PA (- ) FEE SUMMARY ❑ I am exempt under Scc. , B & P C far this reason BACK FLOW PRO IECT. DEVICE 0117715=, SANITARY YN RECEIPTN Owner Date DRAINS - FLOORBOOPANSA, GOND. , , WORKMAN COMPENSATION DECLARATION �❑ INutty, affirm list [have a certificate nfconsenun scl6irssure, or a certificate of 'Workers' Compensation Insurance ora codified copy Nereof(Sec. 3608 Lab C.) which SCHOOLTAX YN FIXTURES-PERTRAPREriti'T# PARK FIRE Y N_ GAS - F.A. SYSTEM -1 INC. 4 OUTLETS rs all employee's under Nis periv Pol cy N RECEIPT N BUILDING DIVISION FEES Company GAS - EA. SYSTEM -OVER 4 (EA) PLANCHECK PIAT ❑ Certified copy is hereby famished GREASIVINDUSTRI, WASTE INTERCEPTOR GRADING FEE ❑ Certified copy is filed with Ne city inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASE'IRAP SOILS FEE SEWER - SANITARY - S'T'ORM EA. 200Ff. ENERGY PRE (This section need not be completed dthe Permit is fomne hundmd Jollara(SIM) or lase.) WATER I EVffR W/VENT/F.LECTR Icm sty that in the performance of the work for which this Permit is issued, i shall not employ any person in any manner eco as to beeume subject to the Workers' PAID Compcuation Lawsof California. Dam Applicant WATER SYSTEM/TREATING Date Receipt Or NOTICE 10 APPLICAN'T:if, after making this Certificate of Exemption, you should become subject to the Worker's Compensation pmvisiuns of the Labor Code, you most NEW RESI DENTIAL PI.M B. SQ. FT.' TOTAL: foMwhIt comply with such provisions or this Permit shall be domed marked. BUILDING FEE CONSTRUCTION LENDING AGENCY SEISMIC FEE I hereby affirm that there is a construction lending agency for the performance of 'f0 AL. ��- IA.ECTRIC THE the work tsar which this peri t is issued (Sec. 3097, Civ. C.) Lender'a Name Lenders Address QTY. MECHANICAL PERMIT FI7H PLUMBING FIA? �- 1 certify that 1 have read this application and state that the above information is correct. l agree to comply with all city and county ordinances and state laws relating to PERMITISSUANCE MECHANICAL FEE buildingamstruction, and hereby authorize representatives of this city to enter upon the above-nsntioned property for inspection purposes. ALTER OR ADD TO MECII. CONSTRUCTION TAX (We) agree to save, indemnify and keep hatless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way assume against said City AIR HANDLING ON]]' (TO 10,000 CFM) in consequence of the grvming of this permit. �L AIR HANDLING UNIT (OVER 10,000 CPM) Si r d'Apphtoo.ontraamr m EXHAUSTROOD (wmuc'n PAID HEATING UNIT (TO 100,000 BTU) HAZARDOUS MATERIALS DISCLOSURE Date RuciptM Will the applicant or future building occupant store or handle hazardous material as defined by the Cors i no Municipal Code. Chapter 9.12, and the Health and Safety HEATING UNIT (OVER I W.WO BTU) TOTAL: VENTILATION FAN (SINGLE RESID) �a x Code, SrcJye, )'0 11 No D Yes Will theePPlicanmrfuwrebuildingcecupantuueyuipmenrordevina whichemit KIazardU air a maminxas as defined by the Bay Arta Air Quality Management strict DOILER- COMP OUP OR 100,000 BTU) ISSUANCE DATE LL Jr BOILER - COMP(OVER 100,000 BTU) ❑ Yes Cl No Agan NEW RESIDENTIAL MECH.—SQ. FT. 1 have read the havudous materials requirements under Chapter 6.95 of the California Health,d Safety Code, Sections 25505, 25533 and 25534. I understand Nat Hulse building does nor curently have a ¢runt, that it is my responsibility to notify the occupant of the reyminemcnts which must he met prier to knumco of a Certificate of Occupancy. V 24 �� /� `� C17Y Uh yup tt rl I lieu ISSUED BY: Owner or authorized agent Date 'TOTAL: OFFICE