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26675 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO .,ot'- FRICAL PERMITNO. APPLICATION/PERMIT PLUMBING-MECHANICAL 26675 BUILDING DIVISION - RUILDING,PROJECIIDEN'1'IFICA'I'ION BUILDING ADDRESS: ! �.f, ems_ SANITARY NO. APPLICATION SUBMITTAL DATE //��J vL%" s' JS UNIT Is LOT OWNERS NAME: PHONE: ONT R'S NAME: LIC NO: N/C CONfROI.# S�pUSSi 257 66 _ "i COwSN• Soy 4o7 /9 � ARCIIITECT/fiNG1NBGR: LIC NO: DD ❑ -7Ll G Y -rL 6 G iwo 4 L oS � x l CONTACT PHONE: pA QiTdY ^.i. F ul �P P HECylRQPERMIT BUILDING PERMIT INFO _,� PEB © t t BLDG ELECT MUCH PERMITISSUANCE � LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION p�z Ihercb um that lam licensed under provisions of Chapter9(commenum,,with qUtfn def(actn%mn3 of Ne Businasend Profusions Code,and mYliun%e is in PANELS F'Zi m CI B Lic.p _ UP T02W AMP9 NQce aw Contractor_ Q 201.IOOOAMPS ZOvrrs� A CHITECTSDECA TION OVER IOW AMPS SQ.FT.FLOOR AREA $/SQ.IT. OZ_p Iundcrsmnd my plans shNlh usedmpublic records. �� - F' m SIGNS ELECTRICAL hN< Licensed Professional OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC. U 1 hereby affpm that 1 am exempt from Ne Camrecrora License Law for the l WW a:cQ following reason.(Section]031.5.Business and Professions Cade:Any city or county TEMP.METER OR POLE INST. yyJ which requires a permit to construct.Man,improve,dcmdeo ish,or repair any ucmm t prior to its iammuce,nlao requires the applicant forsuch peanut to fileasigned statement POWER DEVICES 1 �p 'list he is licensed pursunt to the provisions of the Contractors License Law(Chapter ILO ' 9(Commercing with Section 7000)of Division 3 of the Business and Prufesed.n%Code) SWIMMINGPOOLELECI7UC VALUATION LZ_ or that Sartum 7031.5 by thercfromm M.basis Permfonheascgedexemption. civiny l lotion of UTLETS-SWITCHES-FIXTURES3�j/4Ag tZ,Q Section]031.3 by any eppliwml'ora permit subjects the applicnua ecivilpnJry of e� ��SS ll CC�r L mnot more Nan Ove hundred dollars($500). NEW RESIDENTIAL ELELTR . ClI,asownerofthepropeny,ormyemployeeswithwogesastheirsolecampensmion, S QPT. STORIES TYPECONSIR UHON will do the work,sod the he Cont isnor istadese a w do forsale(pec.]094,Bmineof and Professions Code:The Contractor's License 4w does not apply m m owner of '. propariy who Faulds or improves thereon,and who doessuch work himselfor through his own employees,providential such improvemnrsamnot intmdedoroffertdformle.If, OCC GRO P RES.UNI'T'S however,Mebuilding or improverment is sold within oneyearefcompledo ,the owner. builder will have the burden of proving that he did not build or improve for purpose of sale.). LLa` '+, T h.' ❑ Las ownerofthe propeny,=exclusively, contracting with licensed convectors to fPLUMHING-PERMIT FEE. FLOOD ZONE APN consuucl the project(Sec.70M.Business and Professions Code:)The CoarmclMs ' License law doesnmapply man ownero econamy who buildsorimproveathemn,and PERMIT ISSUANCE who commis forsuch projects with a conuactm(s)licensed promantto the Conpame's License Lear. ALTER (EA)) FEESUMMARY (31earexempt under Sec. B&P C for this reasonOUTSIDE BACK FLOW PROTECT,DEVICE SANITARY Y N Owner Dam RECEIPT# WORKMAN COMPENSATION DECLARATION DRAWS.FLOOR,ROOF,AREA,COND. SCHO LTAX Y_N ❑ Thereby affirm that l have a certificate nfnmsentin self-insure.or a cenificam of RECGIPI'# Workere'Comlesrtionlmunmee ora certified ropy thereof(Sea 3800,Lab C.)which FIXTURES-PER 3'RAP �^ PARK FEE Y N coversallemployee'sunderthittarmat. K GAS-EA.SYSTEM-IJNC.4 OUTLETS RECEIPI'p Policy# BUILDING DIVISION FEES Comp"", GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FRE L 41 ❑ Certified copy is hereby furnished. 96cp ❑ Certified copy is filed with the city inspection division. GREASPogusTRU WASTE INTERCEPTOR GRADING FEE CERTIFICATE OF EXEMPTION FROM WORKERS' REA AP SOILS FEE INSURANCE j flluasationmedoat be completed if the pemdt ie(Drone Frosted dollars($1 W) S R�SANITARY-STORM EA.200FI'. ENERGY FEE or]..) I certify that in the perfonnanmof Ne work for which this ponnot is immeq TF.R (EATER W/VENT/ELF:CTR not employ any person in any mama so es to become subject t Ne c PAID b Py CIanpamiuOa Luwaof California. Doe ATER SYSTEM/IRPATING Data fteceipr# Z+ Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exempuu"yd NEW RESIDENTIAL PLMB. SQ.FT. TOTAL: U) become subject the Worker's Compentrahm provisomofthe Labor CofnMwith comply with such proviaiam or th6 pemuttehall be domed revBUILDING HE Z CONSTRUCTION LENDING AGENCY SEISMIC FEE I hereby affirm that them is'aSc�onvection leading agency for Ne performance of AI: ELECTRIC FEE O the work for which this!06 l.!1�.3097,Civ.C.) �w W tr ICader,Name tJAJ -;If j' "-' PLUMBING FEE ({.-) Lenders Address QTY T MEC II�NICTkLPERMIT 'EEE'' 1 cemfy that 1 have read this application and state that the above infomudn Is hA"! ^ s 'E 'F a correct,le agree to cam MECHANICAL PEE g empty all city and county ortlinmcu and stele laws mletin0m PERMITIS9UANCE72 �-' fA buildingcm ction,ardherebysuNo6nmmeunmfivsofthiscitymemeruponthe C.3 7 above-mentioned property for inspection'ropmes. ALTERORADDTOMECH. 1 CONSTRUCTION TAX G7 (We ogre o save,indem fy and keep harmless Na City of Cupertino agoi et {• liabilities- Is, maende which may many wayaerue against said City AIR HANDLING UNIT(TO 10,000 CFM) Iconse c t the thio Imi[. l AIR HANDLING UNIT(OVER 10,000 CFM) 1 .i'm1uW cMslfia.VeKimGJU [e EXIIAUSTHGOD(W/DUCT) PAID HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO Hill"BTU) Dom Receipt# Will the applicant or future building..part aherenr handle hmormirus material DEATINO MIT(OVER 103,000 BTIJI as defined n by the Capron.Municipal Codandande.Chapter 9.12, d the Health d Safety Core,Section 25332(ep VENTILATION PAN(SINGLE RESID) ❑Yes ❑No IS 0 Will thin contaminantst or s building by he Bay Areequa Air ualityceswhichemit BOILER-COMP DHP OR 100,0(5)BTU) ISSUANCE DATE NsMcnua air aonmminanrs m defined by the Bey Arca Air Quality Mmagem<nt BOILER•COMP(OVER 100,000 BTU) Natrin7 a pTt ❑Yen ❑No NEW RESIDENTIAL MECH. SQ.Ff. I have read the hazardous mmenals requirements under Chapter 6.95 of the California Health&Safety Cade,Sections 25505,25533 and 25534. 1 understand that if the building does not currently have a mnm6 that it is my responsibility to notify the occupant of the requirements which must he met prior to issuance of a Certificate of Occupancy. J \91IXV Owner or authorized plan pans L r V L ISSUED BY1 OFFICE