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25175Aool !CAMT TO PH I IM IMFnR/aIATInN WITHIN RFn LINES. USE BALL POINT PEN ONLY OFFICE BUILDCITY OF CUUAL PERTINO PLUMBING-MFFIE CHT NICAL BUD.DTNG DIVISION APPLICATION/PERMIT BUILDING PROJECT IDEN'DFICATION PERMIT NO. 25375 BUILDING ADORES: SANITARY NO. APPLICATION SUBMITTAL DATE. UNIT# LOT# O ;RSNAMF. HONE: C RACTO' NA�M)E: ' LTCNO V LV N/C CONTROL# CIETECT/FNGINEER: LIC NO: ADDS SS' C .? BUIL'DING PERMIT INFO ONTACT: PHONE: 'c ,# "4,�'A'i=T Y'''c:`e e'f,�, 4 QTY' � r d pHLECTRIC PERMIT, ' .FEE awT OI x BLDG ELECT PLUMB MUCH NCE PERMIT ISSUANCE M`TI '- 0 ❑ ❑ Oy.Z 5100 W E FZ m60. ZOzio�v� 0'Z'-' G I.ICENSEDCONTRACTOR'SDECLARATIO Thereby affirm mail am licensed under provisionsolencing wiN Section]000) of Division 3 of the Business and Professions COode, dmylicenseisin full force and of Liaise Class Lic.k Date 7� 74- C at., ARCHITECTS DEC 1 understand my plans shall be used as public records. APPLIANCES -RESIDENTIAL JOB DESCRIPTION PANELS '--^• UP TO 200 AMPS 201-IWAMPS SQ. FT. FLOOR AREA ' $/SQ. FT. , OVER 1000 AMPS SIGNS ELECTRICAL �© Licensed Professions] Fi C ,0.0.p460 a F 00'3 cc ,� X04 W} LL¢p ay 4 yMo,, FW� O q OWNER-BUILDERinaptfa m the ,RATION 1 hereby nffirtn that I am exempt from the Convector's License Lew for the following mason. (Southern 7031.5, Business and Professions Code: Any city or county ,err repair any structuw which requires- e, alsomcores th applicantpermit to issuance, also re the lican[torsuch rmit to file a signed statement prior quires pp pe g License Law (Chapter thatheis Ilansedp Sectiorotheprovlelons of the Ce Busi Business 9(c.mmeneing with Sation9W0)of Division 3.fihe Bueinaes and Professions Code) or that he is exemprtherefrom and the basis for the alleged exemption. Any violation of Section]031.5 by any applicant fora permitsubjena nalty s the applicant,. civil peof ml more Than five hundred dollars ($5007. o❑ hasnwnerofthepr.p,try,ormyemployeeswiN wages as lheireolecmmpensetion, will do the work,and the structure isnotinwnded oroffered forsale(Sec.004FURmainese and Professions Code: The C.mr.emr'e License Law does not apply to sm owner of SPECIAL CIRCUIT/MISC. 8 v TEMP. METER OR POWER DEVICES SWIMMING L EITE OUTLETS -SWITCH S -Fl VALUATION I L� .TOR S TYPE CONSTRUCTION NEW RESIDENTIAL LECTR S . FT. Q proped,who builds.rimproves thereon, andwhodoessuch workhimsclrmilartghhie own employees. providedthatsacb improvementame not intended or offered beside. if, however, the building or improvement is sold within care yea ofcompletion,the owner- braider will have the burden of proving that he did not build or impasse for purpose f Bale) ❑ 1 a ref aha y an contracting with sedTh e.mmao w OCC. GROUP RES. UNITS TOTAL: a -V ."a } PLUMBING PERMIT, 4 PER Q x � A �- a FLOOD ZONE APN Sec. 7 1, Business dee) Lienseconstruct the project (See. ]044, Ausiows per Professions Code) The Contmcland License Law docs not applyto an owner of property wM10 or, im proves thereon, and PERMITISSUANCE licensed wheamLams[.rsueh pro)ec¢wlN ewnlracmr(s)licensed pureuantwtheComrac[ors Licenser Law. ALTER - GRAIN &VENT- WATER (EA) A FEE SUMMARY - ❑ I am exempt under Sec. , B & P C for this reasern BACK FLOW PROTECT. DEVICE UT IDE PEEK SANITARY YN -f Owner Dare DRAINS . FLOOR, ROOF, AREA, COND, RLCBIPf # WORKMAN COMPENSATION DECLARATION In ms f(Sesure,m Leh C.)c which ❑ rherebynffirmrni Insurer W.rkere'Compensarion Insurance oracenif¢d coey thereof (Sa.3g00, Leh C.) which covers allgnpl�ee' nderjlsk's p. t/ Poliryk (�//y 077 SCHOOL q'AX Y N RECEIPfk pIXTURES-PER TRAP PARK FEP. YN SDIVISION GAS - EA. SYSTEM-] INC. 40UTI.F.TS BUILDING DIVISION PEES C.mpan; _• •-0'� 11Cardinal copy is hereby fumiehed. GAS - EA. SYSTEM-OVFJi4(EA) ww PLANCHECK FEE 2�V GREASFAINDUSTRL WASTE INTERCEPTOR GRADING FEE ❑ CettifiW copy is Pied with the city inspection tlivieion. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE COMPENSATION INSURANCE SEWER -SANITARY -STORM EA, 300FT. ENERGY FEE (This se.d.neeed notbecompletedHNe permit is forme, humdraddollam($100) or 955.) WATER HEATER W/VENT/ELECTR I certify that in the performance ofthe work for which this permit is issued, I shall not employ any person in any manner so as t. become sobject to the Workers' PAID WATER SYSTEM(TREATING Oz+ Z 0 Com,ensation Lawsof California. Dale Applicant NOTICE TO APPLICANL If,after making this Certificate of Exemption, you should Data Receipt It NEW RESIDENTIAL PLMIL SQ. FT. TOTAL: .� ,r lq �iforthwith becomeeubject m the Workers Compensation provisions of the Labor Code, you must comply with such provisions or this permit shall be deemed brooked. BUILDING FEE SEISMIC THE Lk] Q U O U >" V CONSTRUCTION LENDING AGENCY 1 hereby affirm Nat There is a conswction lending agency for lee Performance of Le work for which this permit is issued (gee 3097, Co. G) Lenders Name TOTAL: ELECTRIC FEE Q.. B QTY. MECHANICAL,PERMI'C ,)�?FRR. PLUMBING FEE Leader's Address 1 cerofy That 1 have read This application and saw Thal rhe above information is correct. l agree to comply with all city and county ordinances and slate laws transform building construction, and hereby auNorize representatives of this city to enter upon the above-mentioned property for inspection purposes. PERMIT ISSUANCE MECHANICAL PEE ALTER OR ADD TO MUCH. CONSTRUCTION TAX (We) agree to save, indemnify and keep harmless the City of Cupertino against Iiabili' gmenla, crostsand expertwhich may in any wayaccoe against said City AIR HANDLING UNIT('fO 10,000 CFM) .flee of thi �3 AIR HANDLING UNIT (OVER 10,000 CFM) EXHAUST HOOD(W/DUCT) PAID ignatua fAWlicant/ onlraclor Data HEATING UNIT (TO 100,000 BTU) HAZARDOUS MATERIALS DISCLOSURE Date Receipt# HEATING UNIT (OVER 100,0110 BTU) TOTAL: Will theapplicant or future building ..,act More or handle hazardous material as carried by the Cupertino Municipal Coda, Chapter 9.12, and the Health and Safety VENTILATION FAN (SINGLE ?ESTE) Code, Section 25532(-)? ❑ Yes ) No ISSUANCE DATE Will lheappllmntorfumrebuildingoccupantuseequlpmenlordeviceswhiehemit amadous .ir contaminants as defied by the Be, Area Air Quality Managemet, i me" ❑ Yee No BOILER- COME(3HP OR 100,00s) BTU) j PAID 29 BOILER -COMP (OVER 100,000 BTU) NEW RESIDENTIAL MECH. SQ. FT. I have read the hacwdous materials requirements under Chapter 6.95 of the JUL NVY Cali Health & Safety Code, Seaione 25505, 53J and 25534. 1 understand that H fin.bril' rte. of curtendyh asnantt at tis myre ora ibilitymnolifythe %ald'i ur,ulimm"IIVV rwen 1Uf1 a w aha be rimmi, ame.fa C,rllficata Of Use pans ,rr ISSUED BY:N­Ia'l Own authn ted agent Dare - TOTAL: OFFICE