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27005 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY F OF CUPERTINO e>mmGRF•FtTnTCA' PERMITNO. APPLICATION/PERMIT PLII,MHING-MECIIANICA I. 27 OO5 ILDING DIVISION BUILDING PROJEC9'IDENfIF'ICATION NGADDRESS. SANHARYNO. AINLI ONSUBMIITALDADi 1 O O t \ UNIT# LOl# . 1S NAME: PHONE: ACT'OR'S#AML: LIC NO: l y� ��� t/ NIC G M'ItOLM ARCHITECI'MNGINEER: LIC NO: DDRESS: 7 to a• S,j . 0 v700 �Z2 COVI'AM: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO Lilt� 0 BLDG ELECT PLUMB MI:CIi PERMIT ISSUANCE LICENSED CONTRACTOR'S DECLARATION71 pppL1ANCES-RESIDENTIAL TOB OLSCRIPDON GWCZ I hereby affirm that l am licensed under pmvisionsofChapter9(commencing with F0LFfull force cl D. Section]tNNq of Division Softhe Rosiness alnydfProPossiovs C)ode,andmylicrnseisin PAN IIS QF Zan Lmanse Classlca. Lic.M^ �lr J�1 , UPT0200AMPS �j\ VS \�y\ ��VVA U� tq Qy Date Convector 201-IWDAMPS VV �1 ZFONZ �/I A HI'fHCTS DECIARpTION OVER 1000 AMPS SQ.FT.FLOOR AREA E/SQ.FT. OZ-� IundcrsyA�9lyplan Hall republic records. HFyf-W //////i//���AA SIGNS ELECTRICAL 5�dd Licensed Pr Deal og< WNF,R-BUILDER DECLARATION SPECIAL CIRCUITIMISC. KOyU I hereby affirm that I am exempt firm the Cormarous License Law for the ,die 3 LL oo following aason.(Section 7031.5.Business and Professions Code:Any city or county TEMP.MISTER OR POLE INST. 1-o.O eJ which¢quires a permit to connma,alter,improve,demolish,or repair any sommrt ,WYEmiuissuanc,,also thea licant for such Do File a signed suumcal POWER DEVICES prior requites pp pact gn y, O the he is licensed pursuant to the provisions of the Contractols License Law(Cheerer y� Section g W IMMMG POOL ELECTRIC ,Woo. 9(Commencing w',therermin a Nt)of Division 3oftheind cossand Professions Code) /S VALUATION. � Amy Sectio7031.emptnyaplicnt f the basis for beasegedexemant ill Any vipemltnof OUTLETS-SWITCHES-FIXTURES (/v_/© ^�' �Z G Section]Ol l 5 by any applicant for u fxrmit subjects the applicant m e civil penalty of X90 not moredom five hundred dollars(5500). NEW RESIDENTIAL ELECIR SQ.Fr. K F_o ❑ Lasownerofthepropeny,ormyemploy«swithwegcsaatheirsolecomperuadom STORI TYPE CONSTRUCTION yam will dothework,ande:no License Law not apply to an,Boohoos and Profosinm Code:The CommnoVs Licenu Law does not apply to an owner of pWIsmy who milds nr impnwe,thereon,and who close,s such work Would for through his employ«s,pnrvlAcd that-oh improvements anot imendedofoffemd forsde.If, DCC.GROUP RES.IIN1'IS re however.the building Sr improvement is sold within one year ofcompletion,the owner- TO'f builder will have the burden of proving that he did not build or improve for purpose of Y81e')' QTY. PLUMBING PERMIT E FLOODZONE APN ❑ Las ownerof the property,amexduxively convecting wilt lirenud conb9nm9t0 construe,the project(Sec.7044,Business and Professions Code:)The Contractor's License Law doss not apply ban ownerafpropeny who builds or improvesthereon,and PERMIT ISSUANCE who commels for such projects with a coommior(s)licensed pursuant mita Contractor's ALTER-DRAIN&VENT-WATER IF, Licenu Law. PEE SUMMARY ❑ I am exempt underSec. ,B&P C for this rwson BACK FLOW PROTECT.DEVICES 1.IT-ES SANITARY YN Owner Dae DRAINS-FLOORROOP,ARFA,COND. RECEI N , WORKMAN COMPENSATION DECLARATION . SCHOOLTAX Y N ❑ Thereby uflirm thatlhnve aceniliwte of<onsenuo xelLinsurt,ora cenifcate of FIXTURES-PER TRAP \ RIiCE N WorkersCoupensaion Insurance or a unified copy thereof(Sec.38W,Lab C.)which PARK WE Y N cover,all employee',underthis Fermi,. GAS-EA.SYSTEM-1 INC.4 OUTLETS RITIARPT# Policy B ING IVISIONFEES Company GAS-G.SYSTEM OVER 4(EA) PLANCHEC ❑ Comfid copy is hereby fumishd. ki ❑ Cenirid copy is fled with the city inaPecdon division. GREASEANDUSTRL WASTE INTERCEPTOR GE CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP S COMPENSATION INSURANCE (This aortia ram3m,be completed ifthep.it is forme nundfed dollas(SIW) SEVER-SANITARY-ST MEA.200FT. ENE YFEE Sr Was.) I ccnify thea in the pedorme oat of the weak for which this permit is issued,I shall WATER HEATER not employ any person in any manner so as to become subject to the Workers' PAID Compensation Lawsof Califomia. DamWA .R SYS G Dae tier# O z Applicant z NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should NE •NII LPLMB SO.FT. TO' f- h become subject W$e Workds Compensation provisions of Ne labor Code,you must foMwiN comply with such Provisions or this Permit hdl he d«red revokes]. BUILDING EE �e 0. Q CONSTRUCTION LENDING AGENCY SEISMIC O U 1 hereby affirm on le that them is a construction agency for the performunce of z the work for whistthis permit is issued(Sec.309],Civ.CJ TOTAL: ELECTRIC iE �a OLender's Name PLUS Lender's Address QTY. MECHANICALPERMIT FE]PAID U 1 acidly that I have read this application and sum the the above information is AN AL FEE comet.l agree to comply with ell city sort county ordinances and sum laws relating W PERMIT ISSUANCE I-' h building comuuctlon,end hereby uuthoriee repreaenutives ofthis city tooter upon the C 'TR Cf10NT K (J z aMwe-mentioned perry for in,pectionfeuaposes. ALTER OR ADD TO MECH. (We)air h save,indemnify and keep harmless the City Cupcnian against liabiliaies,ju ets,cos and expenses which may in un ayac ueagaina id City AIRHANDLINGUNITITOID,"CFM) in cmV if the gr ping of Nis permit. /' oAIR HANDLING UNIT(OVER IO,OIp CFM) ,agna ca /Contractor Data EXHAUSTHOOD(W/DUCF') IAZARDOIIS MATERIALS DISCLOSURE HEATING UNI'r('1'O IW,000 BTU) ate Receipt# Will the applicant or future building occupant store or handle haxordnus materiel as defined by the Cupertino Municipal Code.Chapter 9.Q,and the Health and Safety HEATING UNH'(OVER LW.000 BTU) AL.: Code,Section 25532(x)? VENTILATION FAN(SINGLE RESID) ❑Via, ❑No ISSUANCE DATE Will theapplicam or futurehuilJing«cupanmueyuipmentordeviceawhichcmit 9011.ER-COMP(3FIP OR IM."BLV) ' havanlws air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 1 W,000 Brut Distrier? - OCT 1 3 ly ❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. 1 have road he Hazardous materials requirements under Chapter 6.95 of the Celifmnla Heabh&Safety Code.Sectimn 25505,25533 and 25534. 1 undersand that ur L V.-ti,r f if the building does not currently have a tenant,the it is my responsibility to notify the l.U ocupem of the tv,mmmentu which must be met prior ,,ixsuance of a Certificate of ccupancy. Owner or axlnodzed car to TOTAL: ISSUED BY: / OFFICE / 1