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25817APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY CITY OF CUPER'PINO oICDINf:-'ELI., I RI PERMIINO. O APPLICATION/PERMIT PLUMBING - MECHANICAL 5 5 BUILDING DIVISION BUILDING PROJECT' IDENI'[FICA'1'ION o7 ILDINGADDRBSS: SANI'T'ARY NO. APPLICATION SUBMITTAL DATE /`�/''/, y �`'! 10-2-51 & '6N 0� y UNIT LOT �. VZ�3 IiRSy�' ,W T �� NE: kI/YC' CONT C'I'OR'S NAME: � Ll 0 N/C ❑ C(N'IAOLM �ARCHIIECI'/ENGINHER: LIC NO: DD$ / �Z CONTACT: - PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT' INFO BPLUMB MECH PERMIT ISSUANCE � - ❑ ❑ � LICENSED CONTRACTORS DECLARATION APPLIANCES -RESIDENTIAL TOB D[SCRII'I'lON 1 hereby affirm that I um licensed under provisions ofaeyter 9(commencing with Section 1000) of Division 3 ofthe Business and Professional Cade, and my Hermes is In PANELS fun force and effect. License Crass Lie.# UPT0200AMPS Date Convector 201 - 1000 AMPS A 'HITECT DECLARATION OVER 1000 AMPS- SQ. FT. FLOG AREA $/SQ. FT. std my pia 11� ez..- LAC.CI SIGNS ELECTRICAL' �� / P �.r, © .� Lia�nseJ rofcssinnul OWNER -BUILDER DIiCI.ARATION. I hereby off. that I am exempt from to Convector's License Law for the SPECIAL CIRC UDMISC, f li TER following mason.(Section 7031.5, Business and Professions Coda Anycityoreounty TEMP. METER OR POLE INST. ✓ V. L which requires a permit to construct, alter, improve, demolish, or repair any.manctum prior to its issuance, also requires to applicant for such Permit to file a signed statement POWER DEVICES E h of that he is licensed pursuant to the provisions of the Commences License Law (Chapter 9(commencing with Section 9(100) of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VAL A ION ...that he is exempt herefromandthe basis for tltenlleged exemption. Any violation of Secti..n 90315 by tiny npplionm for n pemsh subjects the applicant m a civil penalty if OUTLETS - SWITCHES - FIXTURES mre t mothan f vc hundred dollars ($500). ployees with wagestheirselecomco e Pperty,ormycmaz ❑ Lasownemftro pemion, NEW RESIDENTIAL ELECTR — SQ. PI'. STORIES TYPE CONSTRUCTION will do the work,and the dructureisnot imendedoroffered fmaale(Sm, 104q Business and Professions Code: Em Contractors License Law does not apply to an owner of property whobuildnar impact thereon, and whodoessuch work hlmuffonhrough his - own employees, provided that suchimprovememsam not imemdedoreffered foralu If, OCC.GROUP RES. UNITS however, the buifdingor improvement is sold within one year ofeompletion, the owner- TOTAL: milder will have the burden of proving that he did not build or improve for purpose of sale.). I ❑ ha nwnerofthepmpcny,emexdusivelyamvnctingwithlicensed convucmretn QTY. PLUMBINGPERMIT FHF FLOOD ZONE AVIS onaract the project (Sec, 1014, Business and Professions Cade:) The Contractor's License Lew does not applym anownerofproperty whobuilds or improves dirman,antl PERMIT ISSUANCE' who contracts forsuch projects with a corrosions) licensed porsuanuorhe Commemr's ITESUMMARY License Law. ALTER-DRAIN&VENT-WA'1'F:R (EA) ❑ 1 am exempt under Sec. , B & PC for this reason OUTSID . F :ES BACK FLOW PROTECT. DEVICE SANITARY Y N RECEIPT# Owner Dam WORKMAN COMPENSATION DECLARATION DRAINS- FLOOR, ROOF, AREA, COND, SCHOOL TAX Y ❑ Thereby affirm thutlhnvo acertlMate of ams am toted inarm,. mittruificuteof REOE1110 Wmkerm Compensutiun lnomnceoracenifledenpythereof(Sec.3g00, Lub CJwhich FlXTORES- PHR'IRAP PARK FEE Y N covers all employees under this permit. GAS -EA. SYSTEM -1 INC. 4 OUTLETS RECEIPT p BUILDING DIVISION ITHS Policy N Certified GAS - EA. SYSTEM -OVER 4 (HA) PLANCHECK FEE ❑m copy is hereby famished. GRADING ITE ❑ Certified copy is filed wit the city inspection division. GRFASP./INDUSTRL WASTE INTERCEPTOR CHRTIFICATEOFEXEMPION FROM WORKERS' GRHASEIRAP SOILS FEE COMPENSATION INSURANCE ENERGY FEII This section need not be completed ifthe permit is frrone hundred dollars ($100) SEWER - SANITARY - STORM EA. 200 FT. or less.) I cenifythat in to performanceofto work far which this permit is stand. Ishtll WATP TER W/VENT/ELECTR not employ my person in tiny manner so a to become subject to the Workers' PAID Compenutionlnwsof Califomis. Date li KIMEATING Date Receipt# Applicant NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should NEW RESIDENTIAL PLMIL SQ. FT, TOTAL: became subject to the Worker's Compensation provlslons of the Labor Code, you must forthwith comply with such mvisions or this permit shall be deemed invoked, BUILDING ITT? SEISMIC FEE CONSTRUCTION LENDING AGENCY 1 hereby affirm thi nhem is a cammoreion lending agency far to permnnenm of ELECTRIC 193E the work for whieh this permit is issued (See. 3011, Civ. CJ - handers Name .LcmdeesAddress QTY. MECHANICAL PERMIT FEE PLUMBING PEE 1 certify that I have read this application end state that the above information is meet. l agree to comply with all city and county ordinances and state laws relating as PERMIT ISSUANCE MECHANICAL FEE building construction, and hereby audtorize represcntmlviesof this city to enter upon the CONST RUC'HON'1'AX durve-mentioned property ]or inspection purposes. AI:I I?R OR ADD TO MECI I. I 7 a to sac, indemnify and keep harmless to City of Cupcnino against - limbilies,ju cros,e L Iexpenses which may in any way accrue against said City AIR HANDLING UNIT U 0 I L000 CFM) in 0 e oftheg gof this mtiI. cdmn �' AIR lIANULING UNIT (OVER 10,000 CFMI .ignamre of Applieant/Cnnlmctor Date EXHAUSTUOOD(W/DUC) PAID HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT (TO 100,000 ]1'[ U) Data Receipt# Will the appliumt or future building occupant store or handle fiandous material as defined by the Cupertino Municipal Cale, Chummier 9.12, and the Health and Safety HEATING UNIT (OVER 1fq�l00 BTU) 'roTAI.: Code, Section 25532(u)1 13 Yes ❑ No VENTILATION FAN (SINGLE RIISID) ISSUANCED IC Will theapplicam or future buitdingoccupamxa uequipmentordevicwhichcmit BOILER- COMP LHP OR 100,0(X1 BTU) .. hazarcous air contamionrts as defined by the Bay Area Air Quality Management BOILER - COMP(OVER 100,0100 BTU) District? ❑ Yes ❑ No NEW RHS1DEN'I'IALMECH: SQ.FT A , /tk 1 have read the humorous materiels requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505,25533 and 25534. 1 understandthet as ry d�` Y ifthe building does nm commonly have a moral that it is my ocstionsibility to notify the /(;/ 'J/I#a occupant of the requirements which must he met prior m issuance of a Certificate of /�Jy Cu% Occupancy. v% i VV �... ISSUED BY: - 1• Owner or authnmed agent Dare TOTAL: OFFICE