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27940 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILIHNU- ' (,IRI A, PERMIT NO. APPLICATION/PERMIT PLUMBING-MECHANICAL 27940 BUILUINI:DIVISION BUILDING PROJECT IDENTIFICA'1'I(IN BUILDING �ADDRESS: ��[� '_f I _ SANITARY NO. APPLICATION SUBMIITALDATE (' I✓d 1 ' `Lff+ ( e L-II' UNIT# LOT It OW/71150 W :RS N��A'M((��E: PIIONE: [l n CONTRACTOR'S NAME: LIC NO: (' IT/ 01e t n d n I' /�c�� NIC CONTROL • RCHITECT/ENGINF,ER: LIC NO: ADDRESS: ❑ CONTACT: PHONE: BUILDING PERMIT INFO QTY. ELECTRIC PERMIT FEE BLDG ELECT PLUMB MECH PERM19'ISgUANCE 3Ze00 IC� LICENSED CON'TRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LAS QWz, Ihereby grim that l am licensed underpmvisionsof Chapter9(commencingwith JOB DESCRIPTION pAO2 Serums 7W0)of Divismn 3afihe Bavinexs and Professions Cade,and my license is in PANELS =W E full force and effect. /a--/r F�,m License Class Lick UP TO 200 AMPS C ,Ts �M �ras(� .I� may Dae Contreclor 201-I"AMPS V` Ill` V#k7 R(, ZQNZ ARCHITE=DECLARATION OVER 100.9 AMPS SQ.FI'.FLOOR AREA $/SQ.FT. 0y,_C I understand my plans shall be used as public records. SIGNS ELECTRICAL Licensed Professional ,oe< OWNER-BUILDER DECLARATION SPECIAL CIRCUI'DMISC. OaU 1 hereby affirm that 1 an exempt from the Connector's License Law for the ty3ay Ibllowingremmm.(Section 90315,Bteinesa and Prafe.vsions Cade:Any city or county TEMP.MET ER OR POLE INST. F"a which myuirea a permit m masted,.Iter,improve,demolish,or repair any amemm rior m its irsuance,alsorequires theapplimntfor such permit to file aaigned ate6ment POWER DEVICES W=< that he is licensed pursuant the provisions ofthe Comnal's License Law(Chapter dap 9(cnmmencing with Section 9000)of Division Sof the Busincsx and Professiam Cede) SWIMMING POOL ELECTRIC W M, VALUATION Wor Seelmhe 131.5 by ayappomanf the ba.itxisforrbealleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES 0 I—ZQ Section their see hundred ,($50rmit subjects the applicenno acivil penalty of - W 7S� VD not more than five M1undrcd Jnllars(8500). NEW RESIDI?NTIAL ELEITIR _ KFo ❑ Lasownerofthe propeny,ormyemployecs with wagesastheirsole compensation, SQ.FT, STORIF_S TYPE CONSTRUCTION a3LE will do the work,and the structure is not intendedorofferal forsale(Ss.]I)w4,Business and Professions Code:The Contractors License Law docs not apply to an owner of propedy who buildsarimpmva thetean,and wmdoes such warkhlrmelfonhon,til is own cmployces,pmvided thdsuch improvements are notintendederoffered formle.If. OCC GROUP RES.UNITS however,the buildingar improvement is sold within one years fcampletion,the owner- builder will have the burden of that he did not build or improve purpose o TOTAL: t a proving prove for f Ic TY. PLUMBING PERMIT Las the project (See. 70LI .Business an contracting with de:)The Contractor's Q FEE Fl.00D ZONG APN conLicense the oesnal(Sec. ono Business and Professions Cade)The Con on,and whocaelawd«smtapplywunowncrofprnpenywhosed pursuant thereon,and PERMIT ISSUANCE �aVD whonse La tsI'ortach protects with acontrutorts)licenced pursuunuothe Convacmr's License s Law ALTER.DRAIN&VENT-WATER(FA) FEE SUMMARY ❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES Owe. M xx oe_ SANITARY YN WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOL SAX RECEIPT# N- ❑ Ihercby affirm lhalhaveaccnifica¢of cnnscnno self-i�uum,nracenificam of FIXTURES-PER TRAPRECEIPT'# Workets'Compcnvtlon Insurance or accnifed copy theteafSec.3800,Lob C.)which 0 70 0 PARK FEE Y N / rovers all employee's under rola permit. Policy M GAS-FA.SYSTEM-1 INC.4 OUTLETS RF,CEIPT# BUILDING DIVISION FEES Company Cenificd copy is hereby famished GAS-EA.SYSTEM-OVER a(EA) PLANCHECK FEF, ❑ _ ❑ Certified copy is filed with the city inspection division. GREASEANDUSTRLWAST INTERCEPTOR GRADING FEE CERTIFICATE OF EXEMPTION FROM,WORKERS' GREASETMj I s. SOILS FEECOMPENSATION INSURANCE (This section need not be completed B nue pnmil is(c'Ime hundred dollae($100 SEWER-SANITAR - T EA.200FT.1 ENERGY FEE or le .) 'I: I certify that in the Nnosmance of the work Por which this pe.his issued,lshut s WJTFR HFA ' ENT/ELECB oat employ any person m any rammer so as to become subject to the Waske PAID z Appliaam Cnmpcnsminn Laws n(C.lifomia. Dae A Y " Date Receipt# Q "t z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,youi o RE IDEM IAL PLMB. SQ: T. res became abject ttaoimt o the Workers Conlpenxon powiss of the Labor Cade,you mtm TOTAL: forthwith comply with such provisions this shall be'deemed evoked.e ' _ or perm _..,...,...,.:..•.•. .• BUILDING IEEE ,l W Q CONSTRUCTION LENDING AGENCY SEISMIC FEE O #SQ Z Ihereby.ffths0 rn m there is a covuction lending agency for the performance of (� O the work for which this permit is issued(Sec.3097.Civ.C.) TOTAL: a ELECTRIC FEE / e Lender's Name b [ 0U Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE e�a W I certify that I have read this application and sate that the above inhrrnation it 6. nrrea. l agree to comply with all city and county ordinances and state laws relating to PE IT ISSUANCE MECHANICAL THE <A buiddingemistruction,and hereby authorize reproentsevesorths city m enter upon the U z above-mentioned property for inspection purposes. ALTE ORADDTOMECIL CON$TRUCrIONTAX (We)agree to save,indemnify and keep handess the City of Cupertino against Iiubilities,judgmems,costs and expenses which may in anyway seems,against saidCity AIRIIA LING UNIT(TO U),"CPM) //--��eyuence or the granting of this permit. / I r/ / Y� I_/7 SLI AIRHANDL G UNIT(OVER 10,000 CFM) SignemfrcoApphcanVeam Com "Date 'eJ EXHAUST HOO /DUCD PAID HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 1 BTU) Dee Receipt# Will she applicant or future Municipal C occupant store or handle Health a material az reline]by the Cupcnino Municipal Cale.Chapter 9.12,mal Health sad Safety HEATING UNIT(OVER 100, U) TOTAL:��[xv Gila,$CetlEl 25532(n)Y ❑Yca ❑No VENTILATION PAN(SINGLE RESID) Will theapplicant mfumre mildingrx:cupanmseeyuipmentordevieca which emit BOILER-COMP GHPOR 100,000 BTU) ISSUUpANCEEp��DATE • hemsdous air comaminams us defined by the Bay Asea Air Quality Management BOILER P K 1 0 District? COMP(OVER 100,000 BTU) ❑Yes ❑No NEW RESIDEtITIALMECH. 1 have and the hazardous ma¢riuH reynire5533 under Chapter understand nd the APR 17 1995 Celifomil inStealth&101 cur Code,Sections 5505,t it is and SS34. I understand Nat ifthe building does acsnotcuncmlyhave atcns, that itis tmy o to notify the CIII tar Vu�Cf11 IIVU ocaupam of the tryuvcmena which must be me prior to issuance of a Certipane of (kcupancY. PI Owner or amhanzul agent Date TOTAL: ISSUED s V�� •l✓CG OFFICE