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25790 (2) APPLICANT TO FILL IN INFORMATION WITHIN HED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO IIITILYIIN/:-11-EC. RICA], PERMFFNO. APPLICATION/PERMIT 1'LUMBIFG-MECHAMCAI. C J(�O BUILDING DIVISION IIUII,DING PROJECTIDEN'TIF'ICA'1'ION J r J BUILDINGAU CSS: / SANI'IARYNO. APPLICATION SSUBCMITTAL DATE OUNI LOl'ro —t UB"� WN sn CONTR LIC NO: N/C COMROLM RCHI'l I:C/FNGINEER: LIC NO: ADDRESS: CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO BLDG ELECT PLUMB MECH PERMIT ISSUANCE 11Da' El 0 LICENSED CONTRAM OWS DECLARATION APPLIANCES-RESIDENTIAL HJT Matz l hereby affirm mat l am livensedunderprovisions ofChnmer 9(commencing with 10H UFSCRIPI'ION �00 Section 7100pof Division3ofthc Business and Professions Croda,andmylimmelsinPANELS +l199 full forte and erred. ,Y V UPT0200AMPS 'VE license Class Lic.p .q6y Data Cluddiddl 201-10X0AMPS F-yZ ARCHITECTS DECLARATION OVER I"AMPS SQ.IT.FLOOR AREA b/SQ.IT. ��up- IundcmanJ rn,dum,mll be used®public records. F m F W SIGNS ELEC'T'RICAL '�{{y�j Licensed Professiem Eya'Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. XO y V I hereby affirm that 1 am exempt from the Cnmmed, License Law for the 0034{—n following reason.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST. F�OQ which requires a pernia to construct.alter,improve,demolish,or repair any rmemre EKY$ prior to its issuance,also oximos the applicant forsuch Permit o Gk a signed statement POWER DEVICES C¢O that he is licensed pursuant to the provisions of the Commmors License Law(Chapter a'1o�s, 9(commencing with Section 7")of Division Sof the Business and ProfcssiansGde) SWIMMING POOL ELECTRIC VALUATION yXj_y or that he is exempt therefrom and the lards for the alleged exemption.Any violation bof O1'LETS-SWRCIifS-Fl%TURCS �7< Section 7031.5 by any applicant for a permit subjects the applicant macivil penalty of lf am more Ilan five hundred dollars($500L fStS❑ NEW RESIDINTIALELECPR SQ.FT. STORIES TYPE CONS'TRUC'T)ON Wporo ❑ I,asownernfinepropeny,mmyemployeeawimwagesmmcirsolecomp<rnution, y will do(lie work,and the structure is not intended orndfered forsale(Sm.9044,Business and Professions Code:The Convectors License Lew does not apply In an owner of propeny who builds or improves thereon,and who does such work himself tar through his empinyeas.pmvideJ lha,such impravetnenlaurenn,inOcnJttloroffcrtdforsnlc.IL OCC GROUPEA"UNITS however,the buildingorimprovement is sold within one yearofmmpletion.themener- builder will have the burden of proving that he did not build or improve for purpose of 1 .autwncr of me prnpeny,am cxclusivelY<ontmcling with licensed conlractorsm QTY. PLUMBING PERMIT FEE U'l, ILOOONli nvruct the project(Sec.7044,Business and Professions Code:)The Commemra t cense lawdues not apply to m ownerufpropmy whobulldsm improscsmereon,and PERM1l'ISSl1ANCE whoclmracts forsuch projects with acdrameor(s)licensed pursuant othe Contractor's ALTER-DRAINA,VENT-WATER(EA) FEE SUMMARY Liccnsc Law. ❑ 1 am exempt under Sec. .B At P C for this reason BACK FLOW PRO'PECf.DEVICE O TSIDh FEES SANITARY YN Owner DatO DRAINS-FLOOR,ROOF,AREA,GOND. RECEIPTp WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N ❑ 1hcrebyoffirm that l have reanificale ofconxnuoscl(-insure,ora ifiameof RECEIPTp I��Wnrkers'Compensu,ion lnsurenmorec<nifiedcopy Hereof l$ec.38W.Lab C.)wM1ich I iT\ .,'TA iI r PARK FEE YN mall employee's under this permit. GAS-EA.SYSTEM-I si .40 .EfS RI3CI?IP1'p Policyk _ l I r l I BUILDING DIVISION FEES Company '-BA,SYSTGWOYERI� I 1'IANCHECK FEE [ICenified copy is hereby famished. C] CenifmJ copy is filed with the city inspcninn Jivixion. GRA STIR CF GRADING FEE CERTIFICATE OF EXEMPTION FROM WORKERS' .GREASE TRAP _. SOILS FEE COMPENSATION INSURANCE (This section amid not be completed if me pertnil is!mane hundreddo11ars($10D SEWER-SANITARY-Sl'ORM EA.200FT. ENERGY FEE or less.) I certify thus deme perfony manner torecome subject to issn Workers' WATER f11iATF.R W/VENT/ELECIR nen employ any perm in any manner so m to become subject m the Workm' PAID Umpcn.vahon laws of Califumia. Data WATER SYSTEM/TREATING Date RecciptM Q z Applicant zC) NOTICETO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL: f" iG hccomesubjemoOhe Workers Compemmim provisions or the Labor Code,you must forthwith comply with such provisions or this pool shdl he deemed invoked. BUILDING FIEF. CONSTRUCTION LENDING AGENCY SEISMIC FEE G 1 heron fir thus mem is a convection leaden for the rfomwee of yu Co.C.) y pc TOTAL: ELECTRIC FlEIE U0 'he walk forwhich Chic lre^^it ixissuW(Sec.31199, ly.CJ Lender's Name PLUMBING 17EE I<ndKs Address QTY. MECHANICAL PERMIT FEE U 1 certify that I heir,read his application and slate that the above imromtalion is MECHANICAL FEE correct, lagrtmocomply with ell city and manly mrdinances and su¢hws relating to PERMIT ISSUANCE building comforeion,and hereby sulboric,representatives ofthis city lu enter upon the CONSTRUCTION TAX U z abom mentioned property for inspection proposals. ACT ER OR ADD TO MSCIL (We)agree to save,indemnify and keep harmless the City of Cuperti^u radial liubiliilcs.judgnrems,earls and expenses wbichntay to any way accrueagainnemd City AIR HANDLING UNIT(TO 10,000 CFM) quarts fib granting of`permit. AIR HANDLING UNIT(OVER 10.000 CFM) 9� Si mrc paanVContrnctor Date EXHAUST HOOD(W/UNCI') PAID HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam Recciplro Wil ,eapplicanl or future building occupant store or handle hmmdoua malennl HEATING UNIT(OVER 100.000 BTU) as def nod by me Cupartiro Municipal Code.Chapter 9.12,and me Health and Safety Code,Seedon 255320^ VENTILATION PAN(SINGLE RCSID) ❑Yes ❑No ISSUANCE DATE Will thea licmmrfowrcluddiln and use mrdevices which ami, BOILER-COMP QHP OR 100.010 BTID PP S by the Area Air air contaminants as defined by the Bny Area Air Quality Managemem BOILER-COMP(OVER 100,000 BTU) UISV C13 ❑Yes ❑No NEW RESIDENTIAL MECH. SQ.II', <" 1 have read The harmdous materials requirements under Chapter 6.95 of the Califamtu Health&Safety Code,Sections 25505.25533 and 25534. 1 understand that fife building Joesnol mortality have a lattice,mai it is my responsibility to notify The ��� A «spam of the matti emems which mus,be met pnor m issuance ed a Certificate of (✓p f7 Occupancy. C& Owner or aumonrN ad Date TOTAL; ISSUED B d;A' OFFICE (�