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28217 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. APPLICATION/PERMIT PLUMBING-MECHANICAL BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 28217 HUILDIN SS: SANITARY NO. APPLICATION SUBMITTAL DATE OT# OW .RSN ONE: CONTRAC' �-2'SNA LIC NO: N/C CONTROL# 1RCHITI3C]'/E GINL LIC NO: ADORES ❑ CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO BLDG E .Cp PI E_CI PERMIT ISSUANCE - LICENSED CON IRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION therebyaffirnthatIambe.medunderprovision.ofChapter9(mmmencingwith P400 Sectim700(h flAwisioa3ofthe Business and lhofe..irns Code,and my license is in PANELS yd fail License Class effect. UPT0200AMPS GZ License Class List. y60- Date Comrecmr 201-1000 AMPS a.Rrlt 0' ZONZ ARCHITECTS DECLARATION OVER idAMPS - SQ.FT.FLOOR AREA $/S !T. O z'-'❑ I underaanA my plmts shall be awed es public records, (] P }�`y TNF', Licensed Professional SIGNS ELECTRICAL —L 1111V1]_ w Q OWNER-BUILDERto DECLARATION SPECIAL CIRCUIT/MISC. qq 00.E 1 following greas nffmm that 1 am exempt from the Cosigns o License Law for the 7X¢1 jal-N which requirsaeemit(Section to 7031S,Business sines and Professions Code:Any city or county TEMP.METER OR POLE INST. Jwhidtrequire.ap'.1.toconssthe alter,improve,h pealish,fi repair anystructure P2 (hit rto heslisuued pursunt tthe provisions rvisios of the Comermivo Licele a nse La smmment POWER DEVICES W O thatheisncin.eAth Sectiomthe provisionsof the Commands Llmnsc Law(Chapter d 9(crmmen ' with Section 7000)of Divinion3of the Business end Professions Code SWIMMING POOL ELECTRIC � E, c�mg tui ) ^ VALUATION yl❑y Se@at he 111.1b an""romnnd the basis for bedexemptirn.Any violation of [.. Q 1to % 9031.5 se anarned!eantfoeapumit xubjerus the applicanuo..civil penaltyof OUTLETS-SWITCHES-PIXTURLS ^� re re five hundred dollars($SfNH. NEWRESIDENTIALELECTR S .FT. mWm nwnerofthepmperry,ormyemployeeswiuh wagesastheirsolecompensmirn, Q STORIES TYPE CONSTRUCHON y 11 do acwerk,nndihamnmmto knot intended oroffemd forsale(Sce.9014,Business and Pin i ns Cade:The Contractor's I,erne Law draw not apply m an owner of property slSbuildsrrimpmves thereon,and whodocs such work himselfonhrrugh his .wrempki,eca,acisidolthitainch improvcmemsareaot mmadrdoroffered forsnlc.If, OCC.GROUP RES.UNITS however,the building m aropmermantis sold within one year nfcompletion,the owner- TO builder will have the burden of proving that he did not build or improve for purpose of solo.). - - x ❑ I,as ownerofthe property,am exclusively contracting with licensed contractors m QTY.-:, - PLUMBING PERMIT ` FE8 FLOOD ZONE APN consumer the project(Sec.TAT Business and Professions Code:)The Contra....'. License Lawdoes ort applymanownerrf pr..pertywhobuildsorin oves nation,am PERMIT ISSUANCE who nmtruc[s for such projects withacrnira<roti.)licen.ed pit..aZothe Corametion, AL'IGR-DRAIN&VENT-WATER(EA) FEE SUMMARY License Law. ) - ❑ 1 am exi mpnmder Sea ,B&P C for this reasonUTSIDE FEES HACK PLOW PROTECT.DEVICE SANITARY YN Owner Date DRAINS-FLOORROOF, CONIRPI-171"., , . WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN ❑ Ihereby affirm that l have a cenificam efcousennoself-insure,or a certificate of FIXTURES-PER TRAP RECEIPT# Wmkoo'Compensmion I....aneema ccniBed copy theomf(Sec.3800,Lab C.)which PARK FEE Y N mvem all employee'.mader this permit. GAS-P.A.SYSTEM-1 INC.4 OUPLETS RECEIPT# Policy M BUILDING DIVISION FEES Company GAS-EA.SYSTEM-OVER 4(PLA) PLANCIIECK FEE ❑ Cenlficd copy is heminy famished. ❑ Certified copy is filed with the city inspection division GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE CERTIFICATE OF EXEMPTION FROM WORKERSGREASF,TRAP SOILS FEE COMPENSATION INSURANCE (This srctlonneed not he completed ifthe permit is for one hundred dollars($100) SEWER-SANITARY-ST EA.20BPT car less.) ENERGY FE Icen,fy that in the pertomtarm of he work for which this permit is Bsued,l shall WATER HEATER W/ TALEC not employ any person in any manner so as to become subject to the Workers' PAID Compensation Lawsof Culifern.. Date WATER SYSTEM/ n TIN DamZ Applicant Re ipt# Z Nat ICE TO APPLICANT:IL afErmakir this CediGcate ofli,ma ion,y..,h.ald NEW R. P. PLMB. S .PT. 6 Q became"hwim imply the Worker's Comnsiarfosprovisions ofthe Labor Code,you must TOTAL: C� , fonhwirM1 comply with such provisions Tobi.permit shall he deemed revokrA. BUILDING �r ala CONSTRUCTION LENDING AGENCY ss� SEISIM .�Z) Z I hereby uBlrm That theve is a mos matioa lending agency for the Emmor anoe of EI F U 0 the work for which this permit is issued(Seo.3097,Co.CJ Lenders Nome - O U Lender's Address QTY. MECHANICAL PERMIT= - FEE PLUMBING .E LIU U 1 certify that 1 have rend this application and slate that the above Information is 0.Wi correct. Ingres to comply with all city and county ordinances and state laws retain,to PERMIT ISSUANCE MECHANI ALFEE building construction,and hereby authorize representatives ofuhis city to cnreruponnuo U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONS] MON TAX (We)agree m save,Iaaenmify and keep harmless the City of Cupcnin last liubilities,ju a,costs and expenses whm may ywa seer u . d'aid City AIR HANDLING UNIT(TO 10,000 CFM) memne nmol g inGig It. AIR HANDLING UNIT(OVBR BLOW CFM) Si mm.f t on[ or Orae EXHAUSTHOOD(W/DUCT) PAID HAZAR US MA'T'ERIALS DISCLOSURE IIEATINGUNIT(TO IW,UWBTU) Date Receipt# Will the applicant or future building necmpamt store or handle hazardous material HEATING UNI'T(OVER IOO,OIq BTU) s defined by the Cupertino Municipei Cade,Chapter 9.12,wd the Hwlih and Safety '.de,Section 25532(a)9 VENTILATION BAN(SINGLE RESID) ❑Yes ❑No BOILER-COME(314P OR 1IXkIXq BTU) ISSUA CE DATE 11 Will Neapplimnt or furore huilAingoccupam useequipmem ordeviceswhich emit ., usair contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) strict?" ❑Yeo ❑No NEW RESIDENTIAL MECH. SQ,PC AUG O V(^ ���� I have read the hazardous materials requirements under Chapter 6.95 of the California health&Safety Code,Sections 25505,25533 and 25534. I code....nd that if the building does net meren ly have a minor,that It Is my responsibility to notify theCII Y occupaant of rhe na mine is which must be met poor In ismncoe of a C nificote of Uf 'Ur -I INU Occupancy. Owns o,authot'z dugs Date ISSUED BY: OFFICE