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25508 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELEUI RICAL PERMITNO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 25508 BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMHTALDATE Z -Y/IH`N'� 17 Y/I/1/�` V UNIT LOTH � s Wk HERS NI�ME: ZH (l (� QTY. ELECTRIC PERMIT EEE BUILDING PERMIT INFO 043 ��J g �� 162 Q PERMIT ISSUANCE BLDG SEC_ P UM EC LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL aL�r- JCCB DE 0=z Ihereby affirm that l am licensed under provisions of ChMtcr9(commencing with TOR DESCRIPTION ,00 Section)0(10)of Division 3 of the Buxinesa and Rmfessions Code,and my license is in ppryP,Lg � � Fy.n1E Licen fislifirteandeffect. UPTO200AMPg Q VVy U� License Class Lic.N vFi Q vai Data Coalacmr 201-1000 AMPS Nz ARCHITECTS DECLARATION SQ.FT.FLOOR AREA S/SQ.FT. OVER I"AMPS O ^ ❑❑ 1 understan0 my plans shall be used az public records. 2F W SIGNS ELECTRICALS ne< Licensed Professional] DECLARATION SPECIAL CIRCUIT/MISC. 0.0. �OaU I hereby nffirm that 1 em exempt from 0e CaLicense Low for the too to 3 H.ya following reason,(Section)03 L5,Rosiness and Professions sidna Co Code:Any city or county TEMP.METER OR POLE INST. t E11 J which requires a .an eonstrus,cher,improve,dcmnlish,or repair any suoaure MY� prior to its issuance also requires the applicant for such Permit file a signed statement POWER DEVICES hep that he is licensed pursuon to the provisions ofthe Contractor's License Law(Chapter 9(commencingwith Section)OW)of Division 3o17the Rashness and Professions Code) SWIMMING POOL ELECTRIC V U or that he is exempt berefrom and the basis for dteallcged exemption.Any viotumrt of �C Section 70by tiny applicant for a permit subjects the upplicnnnoacivil penalty of UTLETg-SWITCHES-FIXNRES er not roam Nan five hundred dollars($500). tYm ❑ I,esownerofthepmperry,ormYemployeawithwegesss@eiraole compensation, NEW RESIDENTIAL ELECfR —SQ.FT. STORI ' TYPE CONSTRUCTION will dome vank,and theshuctmeisnot imandedoroffered forsole(Sec.7W,Business and Professions Cole:The Contractor's License Law does not apply to an owner of property whobuildscrimp nvesdommi,and whodoeasudi work himselforthrough his ^' I ED ownemploye maldfigori improvement irardcomplenon,forsMe.If.owner. © Q NITS however,the have t e burden of,mem]that he did one build or improve for theoweeof �J builder will have the burden of proving that he did not build or improve for purpose of 7:2— sal`)' censed TY, PLUMBING PERMIT E A,rE FLOOD ZG P 4 PN ❑ Iuct ownpra prayer (Se perry, , Business and ntraningwithlii The ommctonm Q construct the project(gee. =o Business and Professions Code:)The the rears PERMIT ISSUANCE who ittnxlact does such pplym anith ac nfpctors)whosed puaimlrovea thereon,and _ Liceme Law.forsuchproj<cu withucontracmge)licensed pursuemmthe Conuacmrs ALTER VENT.WATER(EA) Liceme Lew. � � EEE SUMMARY ❑ 1 rum exempt under Sea. ,B&P C for this reason — OUTSIDE FEES BACK FLOW PROTECT.DEVICE SANITARY YN Owner Data RECEIPT N DRAINS-FLOOR.ROOF,AREA,GOND. WORKMAN COMPENSATION DP.CLARATION SCHOOLTAX YN ❑ Ihertby Nfimmthatihaviceccnificen ofconum molt-insure,ora anificaa of RECEIPT 0 FIXTURES-PER TRAP va'Cmployee'iom lnmmncermit. fed copy thereof(Sec.Jg00,Lob CJ which PARK FEE Y N coven all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLEfg CEIPTp PoI�yN BUILD G ISI FEES Company GAS-EA.SYSTEM-OVER 4(EA) PIANCHECK FEE ❑ Candied copy is hereby furnished. ❑ Cerified copy is filed with the city inspection division. GREAS9nNDUSTRL WASTE INTERCEPTOR GkADINGIF16,91 J6 c CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS �� COMPENSATION INSURANCE (This section decd not be completed ifthe permit is for one hundred dollars($IN) SEWER.SANITARY-STORM EA.200FT. EN YFE �• or less.) f I ceallythm in the performance ofthe work this permit is issued,I shall WATER HEATER W/VENT/ELECTR not ploy any perso�nj n any ncr so to become subject to the Workers PAID lemsmion L,Y.=(allfo ' em WATER SYSTEM/IREATTNG Date N 0 ;e Applicant (� Z .. NOTICE TO APPLICANT: ,after s eniaate of Exemption,you should NEW RESIDENTIAL TIME. SQ,FT. IAL: P+ fq become subject m the Workers Compensation provisions of the labor Code,you mutt I" forthwith comply with such previsions or this permit shall be deemed avoked. BUILDING IEE 1 LkI0 CONSTRUCTION LENDING AGENCY SEISMIC FEE 1 hereby affirm Net them is a construction lending agency for the performance of 'IUO the work for Which this Permit is issued(See.3097.Civ,CJ ELF.CI'RIC ,n lender's Name In- LL Lenders Address QTY. MECHANICAL PERMIT FEE PLUMB I/IVE 1 certify that I have read this application and state that the above information is [PAID H ]CAL ER c reci.I agree toe comply with dl city andcounty ordinances and snn laws relating to PERMIT ISSUANCE building construction,and hereby authoniu representatives ofthiscity tuenter alum theSTRUCTION TAX eV above-mentioned property for inspection purposes. ALTERORADDTOMECtI.(We)agreto save,indemnify and keep hassness the City of Culmina againstnonanliabilities,judgmen ,csdexpemses which me ianywayecerueegaimisaidCity AIR HANDLING UNIT(TO I0.JaXCFM) in consequence of @ gtarning o th' AIR HANDLING UNIT(OVER 10.001)CFM) Siguama of ApplicamVConvxamr _ Date EXHAUST HOOD(W/DUCI) HAZARDOUS MATERIALS DISCLOSURE HEATING UNI'I'ITO IN."BTU) Date Re ipta Will the applicant or funre building occupant store or handle haardicus material as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IN."BTU) TOTAL: Cale,Section 25532(a)P VENTILATION FAN(SINGLE RMID) 13 Yes 13No .vim• ISSUANCE DATE Will thallbcantor future huildingnerapnmmeequiPmeat ardevices whi<hemit BOILER-COMP(3HP OR 100.0011 BTU)) fJ�a� BNzpNous air contaminunu as defined by the Bay Area Air Quality Management BOILER-COMP(OVER IN,"BTU) y� District? -4 B D ❑Yes ❑No NF.W RESIDENTIAL.MECH. SQ.FT. �®® I have head the havrdous materials requirements under Chapter 6.95 of the 'l�1 8 19 California Health&Safely Code,Sections 25505,25533 and 25534.1 understand that /S if the building does not currently have a tenant,that it is my responsibility to notify the C/1 sn74 occupant of the requirement.which must be met prior n 1...of a Certifiwe of Occupancy. Ownermauthoriud agent Dae L: ISSUEDBY: J OF