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2500514OC1-- IQZu y�V Zc'`L` 0z KOyC I�•n,0< �Y. :'C o0 W=u t -Z> f=C W�o a3 - APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY CITY OF CUPERTINOsoill'- --- APPLICATION/PERMIT PLUMBING -MECHANICAL. BUILDING DIVISION BUILDING PROJP,C'I IDF.NTIF'ICY]]ON PERMIT NO. O O G v BUILDIN`/G)�AUDR[SS�/-^r y1- 7 I O cK - R SANITARY NO. APPLCAJTII.O`N S1UB///M���Iaaa��aITTAAL DAT. I tel, I r UNIT# LOTp hyV ^FRS NAM. � l �� PHONE: CONTRACTORS NAME: 1 /I��,� LIC NO:� 'DVI ff /©© NIC CONIIRO`L# AIRRCII{ITECIIENGINEER: UC NO: DDRUSS: � ,, pp S tAUNIOVOD IRC!. J tdarEl CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO BLDG ELECT 'WMUCH PERMIT ISSUANCE ❑ ❑ LICENSED COMFACTOR'S DECLARATION Thereby affirm ofisionsof Chapter and mmecense with sat Iion 3 ofth Bussed iness Section7000)of Division3of the Business and Rvfexsiom Coda and my liana is in APPLIANCES -RESIDENTIAL LOB DESCRIPI'1 N �I II �r L) PANELSfull • Liccnrte and i. 1- j Dates' ecr �Cman I� s4( Dam COmI*S UP T02W AMPS 'pl-,L/,!}f C-) r 201 - 1000 AMPS ' ARCHITECT'S DCCLARATION DECLARATION Its, I understand my plans shall e used as public records. 1 OVER 1000 AMPS gQ. IT. MOOR AREA F R1 I �' 1 j Y'1 Cy7 $/SQ. IT. nI,� SIGNS ELECTRICAL 11 i 1 3 Licensed Professional OWNER -BUILDER DECLARATION 1 hereby affirm that 1 um exempt from the ConuacnnS License Law for the j following reason, (Section 7031.5, Business and Professions Code: Any city or county jwhich requires a permit to construct, alma improve, demolish, or repair any sm chum • prior to its issuance, also requires the applicant forsuch permit to file a signed stammer SPECIAL CIRCUMMISC. TEMP. METER OR PO POWER DEVICES E j that he is licensed pursuant to the provisions of the Convectors License law (Chapmr C 9(commencing with Section 7")of Division 3 of the Business and Professions Code) or that he is exempt herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not morethan five bumlrW dollars (551p). I,asownerofthc compensation, ❑ propcny,armyempinded SWIMMING POOL ELECTRIC s— VALUATION Soo Soar OUTLETS-SWITCHES-FlXTURES NEW RESIDENTIAL ELECIR S FT. Q' SIDRIEg 'TYPE CONSTRUCTIOD or ofeed forsalei(sole for sale (Sec. ]094, casinos will do the wok, and the structure isnot Immense and Professions Code: The Contractors LaPo do Licenu taw apply to an owner of property wyeess, J.svnimpmves thereon, and o such or stheren, such work through his encs s oroffifor err, ewofroroffctd for sawn- OCC. GROUP RIS. UNI"IS theesildingdthat provehimpmvementsarene however,theavet a harimprovementissoldwithinoneyea or improve for thrower- builder will have tM1c harden of proving that he did not build or improve for puryrse of TOpAL: QTYPLUMBING PERMIT FEE ale.). ❑ 1, as ownerofthe propeny,amendusivdycontracting with licensed conwetorsm FLOOD ZONE nPN construct the project (Sec. 71,44, Business and Proressions Code:) The Contractor's License lawdass not applytoaaowne(ofpmpeny whobuildsmimproves thereagand _ PERMIT ISSUANCE whocontmns for such projects with aeonvaaorts) licensedpursuanvo the Connector's License Law. ALTER BA ( ) PEE SUMMARY ❑ 1 ren exempt under Sec. , B & P C for this mason BACK FLOW PROTECT. DEVICE OUT FEES SAN? Y N Owner Dat° DRAINS - FLOOR,ROOF. AREA, COND. RECEIPT# WORKMAN COMPENSATION DEARATION CL IM1ercbyafOrmthw l have aoenlfeme afromorfto self .insure, ora unlficme of crs'Compensation Insurance ora certified copy Nereof(Sec.38W, Lab 0)which Policy #Ilr mplgyq iv3(\thispttmit. LL`d144-f ��bh WHOOLTAX Y N RIiCF.IP1'# FIX'1'UkES-PER TRAP PARK FEE YN RECEIPT # GAS-F.A.SYSTEM-I INC.40UTLETS BUILDING DIVISION FEES Company 5'i,-T�Twd. GAS - EA. SYSTEM -OVER 4(EA) PLANCHECKIEE ❑ Cenifd copy is hereby famished. �nificd copy is filed with the city inspection division. GREASFANDUSML WASTE INTERCEPTOR GRADING FEE CERTIFICATE OF EXEMMON FROM WORKERS' COMPENSATION INSURANCE 1 GREASETRAP SOILS PEE (This sectionneed notbe completed ifthe Permit is forone hundred dollars($10i or less.) SEWER - SANITARY - STORM FA. 20(1 ENERGY FEE I certify IM1at in the permonsweenfthe work for which this wemitis issued, l shallWATER HEATER W/VI?NT/ELECTR �• not employ any person in my manner an in to become subject to the Workers Compensationlawsof Califnmis. Date Applic t WATER SYSTEMIMEATING PAID Date keccipnp NOTICE TO APPLICANT: If, after making this Comficare of Exemption, you should become subject no the Workers Compensation provisions of the labor Code, you must NEW RESIDENTIAL PWB. SQ. FT. TO'T'AL: BUILDING IEE forthwith comply with such provisions or this permit shad! od deemed revoked. CONSTRUCTION LENDING AGENCY I hereby It,. that there is a construction lending agency for the pecfec nese of the work for which this permit is issued(SeeNW7, Civ. C.) Lenders Name SEISMIC FEE TOTAL: [�%} ELECTRIC FEE Lmichw's Address QTY. MECHANICAL PERMIT FEE PLUMBING ME ansa 1 cemfy that I have mad this application end stain that the above information is PERMIT ISSUANCE MECHANICAL FEE c.W. lagrcc in comply with all cityand county odlnancesind stain lawsoshdm,to building construction, and hereby auNorire mpapp ndrdves of Nis city to enter upon the CONSTRUCTION TAX above-mentioned property for inspection purposes. ALTE-R OR ADD TO MECIL (We) agree to save, indemnify and keep harmless the City of Cupertino against abili�-' dgms en, cossand ex sea hich may in anY waY ucm '� eeagei msaid City W c oftbe,mourng I is t /mites AIR HANDLING UNIT (TO IgWO CFM) AIR HANDLING UNIT (OVER Io,000 CF17 / S Signature of AMlic Contmrnr Dae EXHAUST HOOD (W/DUCI) PAID HEATING UNIT (TO BOB." BTU) !{EATING UNIT (OVER 100,000 STU) Dom ReceiptN HATARDOUS MAgoccupSDISCLOSURE Will the apphcant or catin. ture Municipal Code. Chapant marcor handle hazardous and Safe,, as define] by the Cupertino Municipal Code, Chapter 9. 12. soothe Health and Safety Code, Section 25532(x)? TOTAL: of .a(. 5Ci7 VENTILATION FAN (SINGLE kI?SID) 11 Y,,' C3 No Will the asoma us, building occupantuse equipment reality BOILER - COMP (3HP OR 1 W,000 BTU) ISSUANCE DATE marts hazardoDionic'? air contaminants as, defined by the Bay Area Air Quality Manngcment scwhgiament DlfVlel? BOILER -COMP (OVER 100," BTU) ❑ Yes Cl No NEW RESIDENTIAL MEC L SQ. 17. I have mad the haranlaus materials tequinemes under Chapter 6.95 of the California 1lealth & Safety Code, Sections 25505, 25533 and 25534. 1 uodersend that ner.pe r rche t of g dos not cuaus w have h must tic t. metre it is my maponsibf. to notify the cu,an of the requirtmens which must od met prim m issuance of a Certificate of pp�� p ' Tam e'V gtl, O Occupancy. ISSUED B4 Owner or archon aid agent Date TOTAL: r 1 uvu