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25868 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO ala LacuitsPERMIT NO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL /N ^�a BUILDING PROJECT IDENTIFICATION L VX I6J V8 BUILD ADDRESS: SANITARYNO. APPLICATION SUBMITTAL DATE NxrIT# LOT# ' OWNE@SNAME PHONE CONT A R'S NA E: LIC NO:, 4S 7� I� G r �NIC7T CONTROLpARC11ITECT/ENGINEER: x LIC NO: ADD SS: p21 CONTACT: V QTY, ELECTRIC PERMIT FEE BUILDING PERMIT INFO e- ' /_ PERMIT ISSUANCE BL G ELECT PLUMB LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL G]c47. m7000aueby f a that Division 3 Of the derstandeap rovisifesions Corer add(commencing with �� IOB RIFT &i-, fall ]Oa0) ffDivision3of theBusiness and Professions Cale,and my license is in PANELS C U full force and effec F License Cls. Lic.R 'UP TO 200 AMPS ` Fly Date Contractor 201-ItN10AMP5 ZO`t ARCHITECTS DECLARATI O Z I undentund my plans shall be used as public records. OVER IOW AMPS f Q fT ARE S/SQ.PI'. ��4y5SIGNS ELECTRICAL Ca� Loeneed Profees.Onul OWNER-BUILDER DECLARATION O U SPECIAL CIRCUIT/MISC F I hereby affirm that 1 am exempt from the Conmamra License Law for the ' w3�m which ngmeson.(&riun]o3L5,Business uel,imrProfessions Co de:Any city nhmetracounty TEMP.METER OR POLE[NST. IS,�� which requires u permit m conswtt,¢her,improve,demolish,or repair any structure s5an prior to its issuance,also requiresthe applicant(orauchpermiuo fileasigned smoment POWER DEVICES 08 that 6e is licensed pursuam m the provisions of the Contractors License Law(Chaptr W yo 9(oommenoing with Smdon]OPq)of Dlvision7of the Business end Professions Cade) SWIMMING POOL ELECTRIC W_rn Onhat he is exempt therefrom end the bvis for W¢aIle ed exam tion.An VALUATION 8 P yviolbaby of SWITCHES- aaa..... Q Section]031.5 M1y any applicant for a permit subjects the applicant to a civil penalty of OUTLETS- FIXTURES I� L BO� Ca not more than five hundred dollars($500). ' 7 es; ❑ hasownerofth<pmpeny,ormy employees withwagcsesrheireolecompensation, NEWRESIDENTIALELECTR __SQ. STORIES TYPE CONSTRUC TION L will Bothe work,and thexwawrels not inmodedoroffemdforsnla(Sec.]044,Business end Professions Code:The Convector's Littnse Law does not apply to en owner of pmpeny who builds or improves thereon,and who does such work Nmselfonhdough his employxs,pravidedthateu<h tittle.If, UNITS however,the building nrimprovemem is sold within oneyearofrompletion,theowner. builder will have the huNen of proving that he did not build or improve for purpose of A ; V� sale.). a I'� ❑ I,asownerofthepropeny,um exclusivelycontracting with licensed contractors m QTY. PLUMBING PERMIT FEE FLO 0 APN construct the project(Sec.7044,Business and Professions Cale:)The Cabddr,rs 'I'E License Law does not apply to anownerofpraped whobuildsorimproves thereon,and PERMIT ISSUANCE who contracts for such projects with sconrrallono)licensed pursuant tothe Contractor's License Law. ALTER-DRAIN&VENT-WATER HEA) FEE SUMMARY ❑ 1 em exempt under Sea ,B&PC for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEE Owner Date SANITARY Y__ry WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT# ❑ 1 herebyaffirm that l have acenificamofenalvitto self-insum,oracertifcateof SCHOOL TAX Y N Wmkers'Compensalion Insurance ora certified copy thereof(See.3800,Lab C.)which FIXTURES-PER TRAP ' RECF.IPTp covers all employee's under this Permit PARK FEE y N Policy# GAS-EA.SYSTEM-1 INC.4 OUTLETS RF.CEIPI'# Company BUILDING DIVISI FEES ❑ Cordiiedcopyisherebyfumished. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE ❑ Certified copy is N<J with the citIs yinspection division' GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE - CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS PEE COMPENSATION INSURANCE (This section neWnot be completed if the permit is foioae hundred dollars Ell old SEWER-SANITARY-STORM EA.200FT. ENERGY FEE orhas.) I certify that in the performance ofthe work for which this permit is imued,lshall WATER HEATER W/VENT/ELECTR not employ any perso n any nner s s to ,EcorR Iect to the Workers PAID z Compens vs f ahfom', a 7 WATER SYSTEMiTREATING Receipt# O ApplicuntTSCA NOTICE TO APPLICANT:I,after making this Certificate Sic i t bur o Code.you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL: H become hwithc mpyt to the Workers Compensation ermitshall beeLaborevod, moat forthwith comply with such provisions Or permit shall be deemed revoked. BUI E yCONSTRUCTION LENDING AGENCY S MI E Z) Z I hereby affirm that there Is a oonstruction]coding agency for the perforrommO of J the eName work which this permit is issued(See 3119],Civ.CJ AL: EC IC Z) U Lenders Address QTY. MECHANICAL PERMIT FEE PLUMB GFEE W 1 certify that I have read this application and state that the above information is y 6i correct Iagree 0 comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECH NICAL FEE r rA building construction,and hereby outhodmrepresentativesofthis city to enter upomhe above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONg UCf10N TAX F7 (We)agree to save,indemnify and keep hortnless the City of Cupertino against liabilities,judgments,casts and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,00b0 CFM) in con enc ofthegr tingofthispennit. n AIR HANDLING UNIT(OVER 10,000 CFM) Signature of Appl'enVContmctor Q401 Dale EXHAUST HOOD(W/DUCT) PAID HAZARDOUS Ming cap DISCLOSURE HEATING UNIT(TO 100,0!1(1 Bill) Date Rec t# Will the the Cupertino ino Municipal occupant erre or handle hazardous materiel as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) T Cade,Section 25532(x)] C1 Yes 0 N VENTILATION FAN(SINGLE RFSID) . Will tair contaminants is are defined by the nBay Area Air unlit Management BOILER-COMP QHP OR 100,000 BTU) ISSUANC DATE Chaknorkars s et, air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) ❑Yes ❑No A NEW RESIDENTIAL MECH.-SQ.IT. ' I have read the bandannas materials requirements under Chapter 6.95 of the 0� a� Culifomia Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that PtiF Plldf / if the building does not currently have a tenant that it is my responsibility tonotify the Iy / Occupant of the requlromcnts which most be met pd..Issuance of a Certificate of Cl l f Occupancy. / Owner or authonzed agent Dote ' ISSUED BY: OFFICE