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24470 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY CITY OF CUPERTINO BUIL IMNU-F.LEU TRICAL PERMITNO. O APPL�ATI /PERMIT PLUMBING-MECHANICAL. BUILDING DIVISION BUILDING PROJKCT]DEN TIFICAT[ON BUILDING ADDRESS:: N y / SANITARY NO. APPWCATIONSUBMITTALDA'IE I Yy I'� • O� / �� 6 UNIT LOTp OWNERS A E: / PHONE: /� CO R CI OR E: lj( .., LIC NO: kRCl11' IEC''/.NGINIEUR: LIC NO: DRESS: ❑ CONTAC'D PEIONIE: BUILDING PERMIT INFO QTY. ELECTRIC PERMIT FEE BLDG ELECT PLUMB MECH PIER Mil'ISSUANCE LICENSEDCONTRACTOROR'S DECLARATION APPLIANCIES-RIiSIDENTIAL 1�L+IQ p a'Z IM1ercby aflirLICE lam liCONTuACTORvisDE L RATI 9(commencingwith VZOWO❑ Section 7")of Division 3 afro"Business end�•P'profess)ioqns Cpade,end my license is in PANELS ' ¢VU Litres,NmAClass efl'em. J/�JR / UPT02MAMPS Ao w License Class L m=y Dow tmcD S 201-18(18 AMPS zOn Z IIITF. S [CLARATION OVER I"AMPS f Q.FT.FLUOR AREA $/SQ.FT. O Z—O I understand myplaits shall be used as ublic Tits. SIGNS ELECTRICAL © I A� LicensedLirensed Thur Y V tK�Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. y 06 V 1 hereby of irm that 1 Am N exempt from e Contractor's License law for the II 3 w H following reason.(Section 7031.5,Business and Professions Code:Any city or county 'TEMP.METER OR POLE:INST. ''U 0 Y which requires a peril to comoral,nheq improve,demolish,or ropair uny structure <� prierm its iseuance,aiso requires the Applicant farmch Fermi".file.signedsmtvmew I'OWIER DEVICES DA E Wp O thw he ie licensed Dorsums to the provisions of the Grmmctn(s License how(Chupur aLp 9(commrncing with Section 7000)of Division 3 ofthe Business and Politicians Code) SWIMMING IgOLIELF.CI'RIC '110N p -,y or that he is exempt herefrom and the basisfor the alleged exemption.Any violation of OUTLETS-SWITCHES- tZa Suction 9031.5 by Any applicant for A Pswitsubm x the da,lisan,to A eivi l penalty of FIXTURES Arts more than five hundred dollars($500). NEW RESIDENTIAL ELGCRt _SQ.PI'. p l,asownerofthe ro rt orm em la enwithwa STORIES 'TYPE CONSIRUCTION K p� ❑ p pe lu y p y d musthei(See.corn,Business y will do Professions and the he Commencot es License Law do s not apply to an Bus and Professiolo Cade:The C sthere o,License Law uch not apply lf an owner is propertywyers,dsarimprovasthercun,andamarr mbrit workhlnrselfnnhrmgh his cmplayees,providedmprvehimpis sold itsarene iewofdmpletircd gartaldurivalf, OCC GROUP RIf.S.UNITS hewevegthe avet a burimprmemem issoldwithinoneyear orcompletion,theosto of TOTAL: builder will have the harden of proving thm he did not buil)or improve for purpose of ale.). ❑ I,ON owner nftbc properly,Am exclusively wntructing with licensed conrtacmmm QTY. PLUMBING PERMIT FEE Iq.000 LONE. APN oostmct the project(Sec.7W,Business it Prn(casians Code:)The Conwctax License Law domast Apply to anownerofprupeny who builds or improves thereon,and PERMIT ISSUANCE who commas forsuch projects with acontractabd licensed pursuant to the Cmanctur's T[iR-pkA1N&VENT-WA'T'ER EA v License Law, l ) FEE SUMMARY ❑ 1 nm exempt under Sec. B&P C for this rcuson BACK FLOW PROTECT.DEV TCB TSTRI FE:. SANITARY Y N Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT. WORKMAN COMPENSATION DF.CLAkAI'ION SCI]001.TAX YN_ ❑ I hereby affirm that l have a cerificam A ccount to self-insure,m.cwtificate ofFIXTUR[S-PER'IRAP at/� RECEIPT# Wurkerx'Comprirsatirni lneuruneemrucenifieJ coPythercof(See.3g00,lath CJ which PARK PER YN "avers all employee's under This pemriv GAS-E.SYSTEM-1 INC.4 OUTLETS RPCEIPT N Policy N BUILDING DIVISION FEES Com ny GAS-EA.SYSTEM-OVER 4(EA) PLANCIIECK FEE OOx cmfied copy is hereby famished. CerREul copy is fled with the city inspection division GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE CF.RTIIICATIEOF EXEMPTION MOM WORKERS' GREASE TRAP SOILS Ed. COMPENSATION INSURANCE (This section need not hecompleted if the permit is for one hundred dollars($1BOB SEWER-SANITARY-STORM F.A.200FT. ENERGY FEE A,lem.) I certify that in the pafmmmce of me workforwhlch this Permit is issued,l shall WATER HI?ATFR WryEN'I'/ELECTR not employ any pernun in Any manner so as m become subject to the Wake.' PAID Compensation Lawsof California. Date WA'I'ERSYSTEM/TREA'TING putt Receipt C Z Applicant Z C) NOTICE TO APPLICANT:If,After oinking this Ccnifctic of Exemption,you should NEW RESIDENTIAL,PLMB. SQ.IT. TOTAL: E-' (A become ubjeel to the Workers Compensation provisions of the Labor Code,you must farthwim comply isimsuch provisions ar this permit shall be decimal revoked. BUILDING FEE CONSTRUCTION 1.ENDING AGENCY SEISMIC FEE Z ,^J Imods,allimr tow their is.,,m,uuctiun lending a,my for the perfo..wam ELECTRIC FEE V O the work for which this permit is issued(Sec.YAG.Civ.C) IL s.. Lenders Name O IU-r Lenders Address QTY, MECHANICALPERMIT FEE PLUMBING FETE 1 c roily that I have maul application And ..in.the above information is correct. I agree to comply with all city and county ordinances and suite laws minting to PERMITISSUANCE MECHANICAL FEE buildingcatnowdon, it hvrcbyamhadze reprnsentmit.ofmiscity memerupan the CONSTRUCTION TAX V above-nontinned pmpcny far inspection purposes. ALTER OR ADD TO MECH. (We)agree to save,indemnify and keep harmless the City of Cupertino against Iiabilities,judgmems,costs and expenses which may in any way accrue Against mid City AIR HANDLING UNIT CTO HL"CFM) co( g thin pe it. AIR HANDLING UNIT(OVER 10,M)CFM) ewrc p can o tr. t am EXI IAUS"T Dood) W/D13CT) PAID HAZARDOUSMATE DESCLOSURE1 1 •1�' - HEATING UNIT(TO I(Ifl,fl(10 PTU) Dam Receipt M Will the aOpIiartorfar.building..,arrtsmrearhandlehazardous am a defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,01)(I HTLB Code,Section 255321.)7 ❑Yes 0N VENTILAI ION FAN(SINGLE RESID) lr BOILER-COMPOHP OR 100,000 BTU) ISSUANCE DATE Will all a icamarfumm building m the Bay equipmem Quality Mormighemit IAOV hazmdnm air conmminanrs us defined by the Bey Area Air Quality Mmagem<m BOILER-COMP(OVER 100,(X10 BTU) Dlso-lct2 ❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. yr `rvE 0,t BAS re 1 have ad the hazardous materials requirements under Chapter 6.95 of the Calif eria Health&Safety Cole.Sections 25505,2M33 and 25534.I understand that Bthe building does nut cwmwIy have a tenant,that it is my responsibility to nosily the mcupam of the requirements which must od met pini to issuance of a Certificate of Occupancy. Owner or authorized Agent Date TOTAL: ISSUED BY: OFFICE