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26139 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY / UICDING-EITCTRICAI. PERMITNO. CITY OFCUPESION APPLICATION/PERMIT PLUMBING-MECHANICAL � 'I n _ BUILDING DIVISION BUILDING PRQIECFADEN1J I'IFICKTION BUILDING ADDRESS: .�+ SANITARY NO. API'LICA3'ION SUBMITI'At,DT `AH ©Ido ; ,O&W II 6& / K- UNIT# LOT is 3—���/T OW ;R$NA PHONE: COMRA 1'OR:S NAME: LI Np. f 111 1 �s 1 LIC N n/ NIC CONTROL p ARCIIITECIyENG !R4, LIC f AD RFS E3 CONI ACI': PHONE: �/��/ /'/• // QTY. ELECTRIC PERMIT - PEE BUILDING PERMIT INFO �� PERUTISSUANCE pO BLDG ELECT PLUMB MECII 1.1 SED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL ❑ I hared (firm that lain licensed under n fCh. ler9c JOB DISCRIPI'ION t�uj y.Z ya provieio so p Commencing with F,WO Section full force adeffecttat n3 Tae Business and Professions Come,and my license is in PANELS \ a UP TO 200 AMPS m?yF<E hare Conuav��J�f^'rte-d vkJC� 201-IXX MPS are SQ.FT.FLOOR AREA S/SQ.14. l-=ZARCI31'I'ECTS DECLARATION Z0,_ 1 understand my plans shall be used as public remains. 'GVBR 1000 AMPS o4�o f,yFW SIGNS EI.ECIRICAL sA�1-� ?/ 6,y�y�[4j Lire ed Proleaslnnnl - 6ra a�WU OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC, XXOy 1 hereby affir that 1 am exempt from the Cmaricam,License Law for the WBLL,F„ following reason.(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST. which requires a peril to construct,alter,improve,demolish,or repair any structure - f Y� prin o .id iscomm,ale)regm aireseapplicxn,for such periuo fileasignee sammem POWER DEVICES Wthat be is licensed pursuant to the provisions of the Convector's License Law(Chapter d n.oy' 9(commencing with Section Division 3ofthe Business and Profession Cade) SWIMMING POOL ELECTRIC VALUATION W❑, or that he is exempt herefrom and the basis for allegW exemption.Any violation of ZGSection 7031.5 by wy.pplicaatfora peri,subjects theapplicant ma civil penaltyin OUTLETS-SWITCHES-FI%TURES _ is,e2Q ^` not more than Five hundred doliuro(ESm)' NEW RESIDENTIALELECTR _SQ.IT. S'I'ORII?S TVPL'CONSTRUCTION y F-o ❑ I.asowneroflhepmpcny,ormyemployeeswifowngesastheirsolee mpenaafion, WE!: will do the work,and the strueure is not mended or offered for sale(Sm. Business and Professions Coda The Contractors License Law does net apply to an owner of . propenywM1obuilJaorimpmves thereun,and whodmxsuch xark himulfrnhroughhis con cmployccoInfavided that such impr.vememsnrenol intended m ail...d 0srmle.If, OCC.GROUP RPS.UNH:S however,the buildingor improvement is sold within one year.(completion,theowner- TOTAL: �O builder will have the burden of proving that he did not build or improve for purpose of sale.). ❑ I,aaowneronhepmpeny,amexclusivelycontnc,ingwimlicenudcon=:omto QTY. PLUMBING PERMIT FEE FLOOD ZONE APSE ousbari the project(Sec.7044,Business and Professions Code:)Tito Contractor's License Lawdoss not apply tom ownerofproperty who builds or improves thereon,end PERMIT ISSUANCE ,mvidaicas fo...chprojaOswithacomr.emr(s)licensed pursuant 1.he Contractors pLTEiR-DRAIN&VENT-WAT (RA) hianac Law. ) FEF.SUMMARY ❑ 1 am exempt under Sec. D&P C for,his ressnn BACK FLOW P C O SIDIi PEES ANITARY Y N Owner ElateRECEIPT# WORKMAN COMPENSATION DECLARATION I DRAINS-FLOG 00 N CHOOLTA% V - N ❑ I hcrehy aftir that l have nernificacofconsent m self-irente,orarmificute of PI%TURES-PCP RBCF.IPf# Wndm'Compensa,inn insurance ort certified copy these.((Sec.Jgm,l<b CJ which PARK EfIlE V N_ covers all employee'a under this permit. GAS.EA.SYS'TEM . .UTLRECEIP`# Policy# BUILDING DIVISION FELS Company GAS-BA. -OVER 4(EA) 'PLAN Cl IECK FHH ❑ Cenlfied copy is hereby hummed. La N-- ❑ Cerified copy is filed with the city inspection division. GREASEANDUSTRI.WASTE INTERCEPTOR GRADING FEE CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE9RAP SOILS FEE COMPENSATION INSURANCE O'his section need not be completed ifthe permit is furrow hundrNdollare(EIWI SEWER-SANITARY-STORM IIA.20017T. ENERGY FEE or less.) I certify that in the performance of the work for which this perit is issued,I shall WATER I[LATER W/VENT/ELECfR out employ any person in any manner so as m become subject to the Worker% PAID Eon ComIsmsation Lawsof Califomia. Date WATERSYSTEWOURATING Data ke t z Applicant z 0 NOTICE TO APPLICANTIf,oftermaking this CeniBcae of Exemption,you should NEW RESIDF.NTIALPLMB. SQ,FT. TOTAL: ZI becomesub mato the Workers Compensation provisions.(the labor Code.you most forthwith comply with such Ens kions or this peril shall he deemed revoked. BUILDING FER wCONSTRUCT ION LENDING AGENCY SEES zMIC FEE 5 1 hereby affr that them is a examination lending agency for the performance of �� U O TOTAL: ELECTRIC FEE !he for which this lisissuW(See.J097,Civ.CJ S Lender's N Leader's pddran;ddreaa QTY. MECHANICAL PERMIT FEE PLUMBING FM 7. U I cenify thin I have reed this application and sale Run be above information la MFW HANICAI,FBB V O crrrcnu lagree set comply with all city and county oNinuocea and sate laws miming to PERMITISSUANCE' l� F•' buildiagcommuction,andhereby,ave smaxa epsarmadvesofthiscity toemeruponhe O CONST RUCTION I'AX U z shove-mmaioned pmomy for inspection purposes. . ALTER OR ADD'TO MECH. �Ef (We)agree to save,indemnify and kap harleas the City of Cupertino against limali,ies,judgments,costs end expenses which may funny wayme......fast sold City AIR HANDLING UNIT(TO I RfNp CFM) _ in con,mlarforofma granting m,his perit. AIR HANDLING IINIT(OVIiR 111.000 CPM) �taMHAUS'1'1100D(W/DUCID Signature of ApplicanUCnnrOor Data A11L: q HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I010,000 BTU) Will the applicant or future building.ecup.nt store or handle Intrusions material HEATING UNIT(OVFR IW,IXMI BTU) 'TO' 0,> as defined by the Cupertino Municipal Code,Chapter 9.12,=it the Ilealth and Safety Code,Section 25532(a)1 VENTILATION FAN(SINGLE RESID) MAN d Cl Yes ❑No BOILER-COMP(JOE OR ImExt BTU) ISSUANCE DATE ' Will the apphrnmrfulas defining ecethe ay Area Air ualityc Management INSPECTION DEPARTMENT Inventions s air conaminants as defined by the Hey Area Air Quality Manugemcnt BOILER+COMP(OVER IU4IX10 BTU) ,Disvim1' ❑Ycs . ❑No NEW RESIDENTIAL MECII. -SQ FF. CIN OF CUPERTINO 1 have read the heradous materiels requirements under Chapter 6.95 of the _ 1Q94 if the wilding dh&Safety Cwlhave Sections15505.25533it andsponsi 1undwmand that 1�a// occubuilding does unicamerally isw have a tenant,that i,is my responsibility a nmiate of ^/mss occupant of the requiretrtenkks which must be met prior to issuance of a Certificate of 'f3 I IIVV �w[�,7 Occupmtcy. ul Owner or authoried agent Data TOTAL:Lif ISSUED BY:'Me- OFFICE �• OFFICE