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26958 (2)__, APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO AUT-11 FAINT('.-RLN.(.'rRl ^ Pr:RMn'NG. BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 26958 BUILDING PROJECT IIIEN'FIF'ICATI(IN BUILDING ADDRESS: �` SANITARY NO. APPLICATION SUBMITTAL DATE SV ?V UNITN Lo p# OW ERS NAME: PHONE: CONTRACfOR'S NA LIC NO: 2T7N 1-4JM l C1 -6So © NUC L-OM'ROL# ORCf11TE(T/ENGINF.I?R: � LIC NO: ADDRESS: ❑ONTACT: PHONE: BUILDING PERMIT INFO QT,Y. - - ELECTRIC PERMIT FEE BLDG CLECT PLUMB MEI{ ❑C PERMIT ISSUANCE LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDElITIAh 709 DESCRIPTION py.Z Iherebyvffrmlhm lamlimaws!nndttprovielans,fChupttt9(commenting with 100Sermonandefivision Jof the Rosiness entl Profusions Curie,and my licrnse is in PANELS C W1. full forceeend effect. FZW License Class Lic.p UP TO 200 AMPS r <n. Dam Contractor 201-1000 AMPS 7ONJ-y ARCHITECTSDECLARAT'ION OVER IOW AMPS SQ,FT.FLOOR AREA S/SQ.FT. I understand my plans shall M used as public records. SIGNS ELECTRICAL Licensed Pmfcssiorel ",M< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. P:OyO 1 hereby nftinn thm 1 am exempt from the Contractor's License Law for the �N following reasons.(Section 9031.5,Business and Professions Code;Any city or county TEMP.METER OR POLE INST. which requires.permit to construct,alcor,improve,demolish,m repair any structure A � pri..rIn it,isuancc,likorequiresiheappliemurorsachpemtintufileaalgnedsm¢mem POW17RDEVICES pt•.' w =W<0 O a that he is ticensed pursuant to the provisions of the Contractor's License Law(Chapter m CLL 9(commencing with Section9W0)of Divlsloa3ofthe Business and Professions Code) SWIMMING POOL ELECTRIC V ION pMy in that he is exempt and the basis for the alleged exemption.Any violation of OUTLET'S-SWITCHPS-ITXTURFS Z 4 Section 7031.5 by any applicant fm a permit subjects the applicant m a civil penalty of rhowever, dion EvchunJmd dollars($500). NEW RliSIDENTTALELEcTR _SQ.IT. IY OpownerofOepmpeny.ormyemployeeswithwagesutheirsolecompmtion, STORIES TYPE CONSIR�ICI]ON a3=° e work,and the structure is not imanded metered 4asle(See.7M4,Business ssions Code:The Contractor's License Law does not apply to an owner of whobuilds or improvestoereoo,andwhodoes such work himselfonhrough his own oyees,provided that such improveraeromot not imcndedoroffered forsale.If, OCC.GROUP RES.UNITS he building orimprovemert is sold within one yearofcompletioo,the owner- TOTAL: builder will have the burden of proving that he did not build or improve for purpose of sale.). ❑ 1,as owner ofine property,amesclusivelymmmming with immadc,nuecmram QTY. PLUMBINGPERMIT FEE rLOOD ZONE MIN conation the project(Sm.7014.Business and Profieniom Code:)The Comracon, PERA1IT ISSUANCE License Lawdcea not apply m an ownerofpmpHer eny who builds orimproves eon,and who cnmruns fiamelb projects widtacontrecmgs)licensed pursuanumhe Commeors gLTP.R-DRAIN&VENT-WATP.R(EA) License Low. FEE SUMMARY ❑ 1 con exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE. SANITARY Y DI FES N Owner AT WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR.ROOF,AREA,COND. RECQI"# SCBOOLTAX YN ❑ Ihercby nflitm that lhavc acertificam of consenno self-insure.ora cenifente of RECEIPTM Workers'Compensation insurance or a cenified copy thereof(Sm.38W.Lab C.)which FIXTURES-I PER TNAP PARK FEB Y_Is covers all employee's under this permit GAS-P.A.SYSTEM.I INC.4 OUTLET S RECEIPT ts PnlicyN BUILDING DIVISION FIDS Comfort GAS-FA.SYSTEM OVER 4(EA) PLANCHECK FEE ❑ Camfial copy is hcrcby fumished. ❑ Certified copy is fled with Ne city inspection division. GREASEBNDUSTRLWASTEIMLRCEPfOR GRADING)l CERTIFICA1 R OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE COMPENSATION INSURANCE U'lik,m6nnneed nm In,completed iflic permit is fortune hundred dollars($100) SEWER-SANITARY-STORM EA.200FI'. ENERGY FEE m less.) I cenifymat lnthe permarro nerof the work for whiehthis pend,is issued,le hall .RHE TER W/VEM'/iLECIR not employ any perstm in any manner so as to become subject to the Workers' PAID Compenamionlnwsof Coliforms. (late WATER SSTEMTREATING Date Receipt# Q Z Applicant NOTICHTO APPLICANT:IL aftermaking this CenificarpC TOTAL: o NF.W RFSI ENTIAI.PLMB. SQ.Ff. H Isnsme subject m the Worker's Compensation provisions ust � , forthwith comply with such prevision or this perom shot[ BUILDING FEE CONSTRUCTION LENDING AGISEISMIC FEE z I herebyaffirm thuuhe.isa enrewetion leningerg 1-; ELECTRIC rEE U Orthe work for woichthis permit is issued(Set,300.Civ.C P larder's Name - Lenders Address Q L A CAL PERMIT FEE PLUMBING FEE U I certify that 1 have read this application and state tom th hove info is correct.la res to empty th all cit and ordinances an Temlawsrelatiu let P[ MIT ISSUA E MECHANICALFER a g pYw'i yon ry, 8 ` � Fto huildingconxrnction,Itudherebyawhuriurepms ntmivesofthis tymcnterupontbe CONSTRUCOON'fAX U Z above mentioned progeny for inspection purposes. ALTER O DDTOMECII. (We)agree to save,indemnify and p hamtless the Ci penin,a'matt l iabilitiex,judgntents,cost nJ expects ich any wv cru against suiA City AIRF DLING UNIT(TO IO,OW CFM) in Can uence of th tin milt on HANDLING UNIT(OVER 10,000 CIM) stir r Siaturc.d ApplicanUCant ter na EXHAUST HOOD(W/DUCT) PAID 1{plARDOUS MATERIALS DISCLOSURE BEATING UNIT TIO 100,1100 BTU) Dale RweiptN Will the the Cupnt or ertino Munire cipal Cng ode. Chapter 9.12, or and Ilia Health and 1 uJefinW by the Cupertino Municipal Code,Cheerer 9.12,end the Heahh and Safety IIEATING UNIT(OVER II%1,0110 PTU) IOTA Code,Smti 25532(n)? 13 Y. 11 No VEN ILATION FAN(SINGLE RPSID) ❑ Will the applicant or forum huilAing acupem use equipment or devices which emit BOILER-COMPLIHPOR IW,OW RTU) ISSUANCE DATE hamrdaus air contaminants u defined'by the Bay Area Air Quality Management BOILER-COME(OVER Ul BTU) Diartict? ❑Yes ❑No NEW RESIDENTIAL.MCCII. SQ,Ff. 1 have read the Immu us materials requirements under Chapter 6.95 of the California Healthy gaietyently Sections25505,t it and25534.1undeenti tt AUG Q 7 199 - ifthe building Aces not currently have mnanWhat it is my responsibility mnotify the vu try �Q ccupant of the rcyuirements which must he met prior m issuance Of u CcrtifiCum of 7 Occupancy. CI Oomernrmilimized agent Date TOTAL: ISSUED BY: Vllc 'jl� OFFICE