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24706 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO PLUMBING-EIPERMITNO. �a B O APPLICATION/PERMIT - PLUMPwc.MECHANICALTIFIL 4 BUILDING DIVISION NUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: SANITARY NO, APPLICATIONSUBMITTALDATE D r UNIT# LOT# 1 c1 O NF.RS AM PHONE: CONTRACTOR'S NAME: LICNO: `3� NIC CONTROL#^4 1S,- 3 3 scti T R HITEC'/ENGINEER: LIC NO: ADDRESS: I 31.5-3 CONTACT: - PHONE40 : QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO BLDG F.1SUCH PERMIT ISSUANCE � IIT�Iiy LICENSED CONTRACTOR'SDECLARATION APPLIANCES-RESIDENTIAL JOB�PTION Opt 00 Ih7") ffrmision that I amlicenBuinssand rifesio Chapter and(commencing with P�1 O E Semon 7000)of Division 3 of the Business and Professions Code,and my license is in PANELS {�U Vv Litanfull Classe and effect. GZ�wu License Class Lic.# UP T0200 AMPS y]NData Contractor 201-I"AMPS F m ZARCHITECTS DECLARATION ©SQ.Ef.E1,QOR AREA S/SQ.FT. ZO ry^ OVER'No Amp' I onto O Z—a I understand my plans shall be used as Public records. �r3 j SIGNS ELECTRICAL ,�V 1-„ � �2 Lmensed Pndessronal OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. I K 'OaU 1 hereby affirm that I am exempt from the Contractors License law for the 9 1 `� cb W, 0.t sti following reason.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE MST. cb which requires a permit to construct,alter,improve,demolish,or repair any structure a� prior to its issmnce,also requires the applicant for such Permit o file asignW satemem POWER DEVICES qO that he is licensed pursuant to the provisions of the Contractor's License Lew(Chapter 4•xe04 9(cornancrong with Section 7").fDivision Julius,Business and potassium,Cede) SWIMMING POOL ELECTRIC VALUATION WM, arthritic is exempt therefrom and the basis for the alleged exemption.Anyviolatumcf [—Za Section 7031.5 by any applicant for a permit subjects the applicannoacivil penalty of OUTLETS-SWITCHES-FIXTURES O not more than five hundred dollars($500). C w ❑ I,asownerofNepropeny,orm to eeswithwa esastheirselecom NEWRESIDENTIALELECTR _SQ.FT. W yemp y g Pensiioq STORIES TYPE CONSTRUCTION 4 will duthework, nsCand e he Corei,not is License La do es not apply to an Business and Professions Code:The ves tmemrs and Law does not apply lf am owner of ow Peng who builds orimpraves lh impm end whodoes such work oroffe mthrough his employees,p building or improvement ne iorodedmraffered the owner. OCC GROUP RES.UNITS bowevegillhave the buries of ishat he noon build of completion,the T T builder will have the budcn of proving that he did not build or improve for purpose of ale.). ❑ Mas the ,act(Se pang am osmesis and contracting s C.dceoThe Commoto to QTY, PLUMBING PERMIT FEE FLOOD ZONE qpN tense the project(Sec.704q Business and Professions Crimp The Come ars License Lawdoratich prof manwith who sed ds pursuant wtee theme an PERMIT ISSUANCE �� whence Law.forsuch projects with a<ontructorts7licensed pursuanuothe Conrcacmr's License Law. ALTER-DRAIN&VENT-WATER(EA) PEE SUMMARY ❑ I an exempt under Sec. ,B&P C for his reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES OwnerSANITARY Y N Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT# WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN ❑ Ihereby affirm that l have a certificate ofconsent toself-imme,m itcenificiteofFIXTURES-PER TRAP RECEIPT# Workers Compensationlnsurance oracenifiedcopy thereof(Sec.3g011,LabCJ which PARK FEE YN covers all employee's under this permit GAS-EA.SYSTEM- INC.4 OUTLETS RECEIPTp Policy# BUILDING DIVISION FEES ay El Certified copy is hereby famished. GAS-EA.SYSTEM-OVER4(EA) PLANCIECK FEE ❑ C ❑ Certified copy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE 'CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE COMPENSATION INSURANCE (This section used not be completed ifthe Permit is forem,hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. or less) FJJERGY FEE I certify that inThe performance of the work for which this permit is issued,l shall WATER HEATER W/VETTLELECTR not employ any person in any manner so as tobac b1ery,toyra Workers' 7-. lbmmfipwlyrwsof Califomia. Date /^ ��� `mss WATER SYSTEMITREATING PAID Dare Receipt# Q PPlautra NOTICE TO APPLICANT:If,ofter making this Certificate of 9xemption,you should —SQ.NEW RESIDENTIAL PLMB. FT. TOTAL: V) become subject to the Worker's Compensation provisions of the Labor Code,you must a forthwith comply with such provisions or this pe it shall he doomed revoked. BUILDING FEE pW, z CONSTRUCTION LENDING AGENCY SEISMIC FEE I hereby cif'.In.,be.is a acursamount lending agency for the uh rromoo of V O the work for which this Permit is issued(Sec.3097,Civ.CJ ELECTRIC FEE Lender's Name C U Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE I certify that 1 have read this application and state that the above information is ti hw correct.I agree 0 comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE buildingconswetion,and hereby ambonxe representatives ofthis city incineration the U 7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECI I. CONSTRUCTION TAX F7I (We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,judtfonts,costs and capon.,which may in any way accrue against said City AIR HANDLING MIT(TO 10,000 CFM) in consequence of the granting of this Permit. AIR HANDLING UNIT(OVER 10,000 CPM) Signature of eliliceat/Conrcaetor Data EXHAUST HOOD(W/DUM PAID HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO ROME BTU) Dare Receipt# Will the applicant or future building occupant store or handle hazurdom material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,10100 BTU) TOTAL: Coda,Section 25532(a)? 13 No TI ❑ a)? VENTILATION PAN(SINGLE RCS EE Will the applicantorfmure buildingoccup rmu.equipmentordeviceswhieh emit BOILER-COME QHPOR[ffl,"BTU) ISSUANCE DATE Sardous air comemimants as dafnul by the Bey Area Air Quality Management pp (� ivdcf BOILER-COME(OVER 100,00)BTU) PAID 11 Yes El No NEW RESIDENTIAL MECH.—SQ.FT. I have read the hazardous materials requirements under Chapter 6.95 of the JAN 26 1993 California Health&Safety Cade,Sections 25505,25533 and 25534. 1 undersmnd that lithe building does not currently have ast he met itis my responsibility to notify the Gs'\Jm, occupant of the requirements which must M mer priono issuance of a Certificate of ` , U II occupancy. Ownar m authnnsed agent Date TOTAL: ISSUED BY: OFFICE