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24702 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO - BUILDING-ELECTHICAL PERM]TNO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL Q.�O BUILDING PROJECT IDENTIFICATION T BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE J' �1�\ /� UNIT# LOT# ` -01`rea OWNERS AME,: PHONE: NTRA ,RSNA LICNO: `V VVVV S I O 0. p N/C CONTROL# Is*OWNERS ITEC /ENGINEER: I/1, LIC NO: ADDRESS: - 1 qU ❑ CONTACT: PHONE: `� BUILDING PERMIT INFO 1 QTY. ELECTRIC PERMTT FpFE �✓� 5'O^S�I-1�� PERMIT ISSUANCE, i BLDG ELECT PLUMB MECII (J © ❑ ❑ LIC D CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOeB D�'�5���RIPI'ION nzz I hereby uffimnhm l am llcemcdunderpro...mmofChaptw9(commeacingwith FO r(-A_ in00 Seainn 7fH10)of Uivisiou3of theBusiness and Professions Cade.and mylicenseisin PANELS �1-[QhyI — �-fz FF L"i"a eend effect /-} q UP TO 200 AMPS �/'YCOt,(.JSI-LCe' F Z W Licetse Cla s Lic.# mora Dare I Contractor 201-1IXI0 AMPS FON ARCHITECT'SDECLARATION SQ.FT.FLOOR AREA $/SQ.PI'. O y r: OVER 1!1!10 AMPS ,t i—C7 1 understand my plane shall be used as public records. �� I F 61 BIONS ELECTRICAL Licensed Professional OWNER-BUILDERDECLARATION - SPECIAL CIRCUIT/MISC. O�O 1 hereby vftino that I ant exempt from the Commctore License Law for the rFic following reason,(Section 9031.5,Business,and Professions Code:Any airy m county TEMP.METER OR POLE INST. JwhleM1 reyuires a permit m umsbum,alter,improve,demlish,or repar any aruaure Y� prior to its issuance,also requires the upPlicentfocsoch permit In file nsigneJ dlalement POWER DEVICES p that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter e0.d 9(comncreing win Section7000)of Division 3of the Bininexsand Professions Code) SWIMMING POOL ELECTRIC VALUATI ' co or that he is exempt herefrom and the basis for the alleged exemption,Any violation of pUTi.FTS-SWITCHES-FIXTURES 6 Section 9031.5 by any applicant for a permit subjects the applian[o a civil penalty of �r `►1 not mhan five om tve hundred doll ars($500). . . b/ 01m 11so I,uwneroftheproperty,ormyemployeeswithag wesasdsirsolecomNP.W RP,SIDHNTIAI.ELECTR 3 iTSTORIES pensation, Q - TYPE CONSTRUCTION ywill dothework,and the structure is antimended proffered forsale(See.7044,Business and Professions Code:The Contractor's License Law does not apply to an owner of propertywhobt ildsorimprieves misconstrued who does such workhimselforthrougb his monernployces,provided thatsuchimprovementsare not intendedmoffered hassle.If, OCC.GROUP RES.UNITS however,hebuilding or improvement is sold within one yeworcompletlon,the owner- T TAI: builder will have the burden of proving that he did not build or improve for purpose of 1 sale.). ❑ I,as ownerofine property,am exclusively contracting with licensed rout rano 1,, QTY. PLUMBING PERMIT FEE FLOOD ZONE APN onstreet the project(Sae.7044,Business and Professions Code)no Contractor's r License Lawdoesnot apply to anowearofproperry who builds or improves theneogand PERMIT IS who contracts forsuch projects with acontracor(s)licensed puramalto the Commucmr's ALTER-DRAIN T License Lew. FEE'SUMMARY ❑ 1 am exempt under Sec. B&P C for this reason BACK FLOW PR ECT:HE 1 ' OUTSIDEFEES ANOTARY YN OwnerDam RECEIPT# WORKMAN C MPENSATION DECLARATION DRAINS-FLOOR, OOF, RE SCHO TAX V N . ❑ Thereby afOrm thm lhavaamnifiute of conswno self-insure,orncutifiwo of FlXTURES-PERTROATE RECEIPT Of WorkeelCompensation lnnerance or a certified copy thereof(See.3800,Lab C.)which ARK E Y N aversallem ayce'sunde,lpt���CLny1. '>e, GAS-F.A. STIiM-I INC.40UTLETS RECEIPT# .u'.It !Y^A 1».� BUILDING DIVISION FEES GAS-EA.SYSTEM-OV 114(EA) PLANCHECK FEE ❑ CertiOedwpyis eby furnished. Certified arpy is fi ed with the city inspection division. GRPASIVINDUSTRL WASTE INTERCEPTOR GRADING PER CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE COMPENSATION INSURANCE (This section need not becompleted ifthe permit is fomnehundred dollars(SIM) SEWER-SANITARY-STORM EA.20OFT. ENERGY FEE or lea,.) I certify that in the performance of the work for which this pewit is issued,i shall WATER HEATER W/VENT/F.LECTR not employ any person in any manner sa a subject to the Workers' PAID Compensation laws of Califamia. D comp ser WATER SYSTENUTREATING Date Receipt# � z Applicant C) NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.IrL TOTAL: rn become smucw to the Worker's Comppesvtian previsions of the Labor Code,you must forthwith comply with such provisions or this Permit shall be deemed revoked. BUILDING FEE [� CONSTRUCTION LENDING AGENCY SEISMIC FEE Z I hereby affirm that here is a construction lending agency for the performance of C) the work for which this permit is issued ISw.309Y,OIs.C.) TOTAL: ELECTRIC FEE 4 �y Lender's Name ` Lender's Addreea / QTY.. - -r MECHANICAL PERMIT- - FEE PLUMBING FEE U I certify that 1 have read' is application and stale Ila[the above information is " W correct.I agree to comply with all city and county oninancesand state laws relating to PERMIT ISSUANCE. MECHANICAL FEF. Wildingconsrtucdon,and lareby aummos,RImesentatives of thix city to enter upon the CONSTRUCTION TAX 7 above-mentioned property for inspection purposes. ALTERORADDTOMECIL F7 (We)mince In save,indemnify and keep harmless the Cilyof Cupertino against iiNklies,judgments,costs and expenses which may in any way accrue agirmad aid City AIR HANDLING UNIT(TO 10,000 CFM) in equuce of the ytunin finis permit - �ylryar ����}� AIR HANDLING UNIT(OVER 10,000 CFM) '7 / //An i.� a��/X[.IJL/��� EXHAUST 11000(w/DUCT)i�wreo Ap c nVComummr Dote PAID HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,OW BTU) Data Receipt# Will the applicant or future building occupant door or handle northers material HEATING UNIT(OVER 100,000 BTU) as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety Cade,Section 25532(a)7 11 Ycs *NoVENTILATION FAN(SINGLE RESID) Will theapplicarlorfunmebulldin occupant use equlpen[ordevleos whichemBOILER-COME(THE OR 100,000 BTU) ISSUANCE DATE truncations it contaminants vs defined by the Bay Arco Air Quality Management BOILER-COME(OVER IMOW BTU) g.� Uisnin? T ❑Yes 7 No NEW RESIDENTIAL MECH. SQ.Fr. AID I have read the hazardous materiels requirements under Chapter 695 of the ��� �� Cvhe bit a Health s Safety Code,Sections 25505,25533 m r 25534. 1 responsibility to r tit that if the building does oat cortically have u!coma!,that it is my responsibility m notify the ' occupant of the requirements w ch must be met prior tu isrvvnce of a Canl!cote of CITY 0 e p cY. Cur 1111W/ ,:. Yom. ,,1� 9� O n umhori ngem � TOTAL: ISSUED BY: OFFICE