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24492 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CLLY OF CUPERTINO BUILDING-ELEC'T'RICAL PERMIT NO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL. - BUII.IIING PR(CIPC T IDEN'TIFICA'TION 24492 '-BUILUING ADDRESS: I SANITARY NO. APPLICA'T'ION SUBMITTAL DATH 79 5 �d UNIT# LOT# OW M S .nl I � I pI1pN: s CD ' C'O 'S A E: /y�� /�x' C L/I C NIC CONTROL# ANCIIITECI'/EN INFER: K l/7f G/f(✓CfS.I.1(O,NO: A Ift, J�� J v" TM CONTACT: PHONE: QTY (ELECTRIC PERMIT FEE BUILDING PERMIT IN170 BLDG .LHCT PLUMB MECII PERMIT ISSUANCE El El LICENSED CONTRACTOR'S DHCLARA1'TON APPLIANCES-RESIDENT'(A], I hereby (firm that l aniicensed under p gwith JOB DESCRIPTION OZZ Ye pad profesionsCter and mmeocin +1100 SedTons.and I Division 3of the Rosiness and Professions Code,and my license is in PANELS faly F Lite., and cl 5 . - 4FZW Da n. Cla. Lies C) UP T0200 AMPS m6y Dee Comm-Sr�Olr - 201-1100 AMPS ZOyS AItCHITL'CT'SUECIARA'TION OVER IOW AMPS SQ.IT.FLOOR AREA $/SQ.FF. Oz-0 I understand my plans shall IN,used as public rectors. Fro�w SIGNS ELECTRICAL. J Lmcnscd Professin al �C�a OWNERTUILDER DECLARATION SPECIAL CIRCUIT/MISC. rsx'O q I hereby affirm that I um exempt from the Contractor's License Law for the �1 �m following remon.(Sation]lGl t,lJusiness unJ Pmfcssions Codc:Any cityor roomy TEMP.MCI JR OR POLE INST. 1=iii_01 which requires a permit to..throet,ober,improve,demolish,or repair any smcmre Fm W}� prior to its issuance,also requires the applicant For such permit to file a signed statement POWER DEVICES , arty KBO that he is licensed pursuant the provisions of the Cimantemr's License Law(Chapter 2%0�' 9(commencing with Section70n0)of Division]note Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION W, normal he is cxempnhcrefrom and the basis for the alleged exemption.Any violmionof hZa Station]831.5 by anyopplicant fora pe.itsubjce,a the applicant too civil penalty of OUTLETS-SWITCI Itis-FIXTURIE; 04 m nm.,are than five hundred dollars($500). . CII,asowneroifthe propeny,ormy empinyceswith wages as theirsolecnmNEW RFSIDIiNT1A1.ELECB Spensation, Q PT. STORIES 'TYPE CONSTRUCTION S _ willdmhe work,enJ thcswmure is notimenJcdoraffereJ forsele(Sw.]of4,Busin<ss and Professions Gale:The Contractor's License Law does not apply to an owner of property who build or improvestheram,and whodoes such work himselforthmugltItis ownemployees,provided that such improvememsarcnot intendedoroffemd formle.If. OCC.GROUP NIS.UNI'T'S however,the building or improvement is sold within one year ofeempletion,the owner- TOTAL: builder will have the burden of proving the,he did not build or improve for purpose.I' taEl QTY. PLUMBING PERMIT FEC FLOOD ZONE nPN ❑ 1,as owner proof th(Sec.7414, urines a prof..loong k Coth de:) edcommemrs to Licensed the project(Sec.to No Business and ywho bons Cod prove Cerear,oh License Lawd«snot apply to enownerofpmpenywhn buildsorimpmves thereon,and PERMIT ISSUANCIi who contents for such projects with acantrecoods)licensed pursuant to the Contractors ALTER-GRAIN&VENT-WATER(EA) FEE SUMMARY License Law. ❑ I sm exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE SANITARY YN Owner Date DRAINS-FLOOR,ROOF.AREA,COND. RECEIPT# WORKMAN COMPENSATION DECLARATION SCHOOLTA% YN I ltercby arfina that I hove a certificate of consent tocalf-Insure,nr o wnifente of RECEIPT# FIXTURES-PER TRAP ukers'CnFmmpoeyn�s�a}t5iyn�n lnyyysu��+mpppnepppe�aoggqrwwwuse���enifieJ copy thereof(Sec.38W,Lab C.)which PARK FF.Ii Y N Policy#le`pA 1�� NIiCE119'# GAS-FA.SYSTEM-)INC.4 OUTLETS Company C BUILDING DIVISION FEES GAS-LA.SVSTEMOVER4(EA) PLANCHECK IEE ❑ Certified copy is herby famished. "Certified copy in fled with the city itolwetion division. GRLASE/)NDUSTRI.WAS'M INTERCEPTOR GRADING ITE CERTIFICATEOFEXEMPDON FROM WORKERS' GREASE TRAP SOILS FEF, COMPENSATION INSURANCE (This ardionneedma to completed ifthe permit is for one hundred dollars(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY IEE or loss.) I reality that in theperfisrmance of the work for whichthis permit is issued,l shall WATER HHA'I'ER W/VENT/I!LECTR not employ any person in any manner aro as to become subject as the Workers' PAID Z Compensminn Lawsof Culifomia. Date WATERSYSTEM/TREATING Dare Receipt# Q O Applicant ' 0 NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should NEW RES)DENTAL PLMB, SQ.Fr. TOTAL: tibeconto otorO ro the Warke,'s Compensation pnovixinabof the Labor Cudc,you must > fnnhwirh comply with such partitions or this permit shall be deemed revoked. BUILDING THE W z CONST RUE, C'I'TON LENDING AGENCY SEI SM IC FE ^a 1 hereby affirm that there is a eontweti an lending agency for the pwhim osoc of U O 0e..,it for whichthis permit is issued(Ste.3097,Civ.C.) TOTAL: ELF.ITRICIIE Leader's Name EL IE F Lende's Address - QTY. MECHANICAL PERMIT ELE PLUMBING FEEU I certify that I have readmit application and xlate that the above information is OW.. correct.I agree to comply with all city and county ordinances and state laws reining to FERVID ISSUANCE? MECHANICALFER t F' ti building conswetion,and hereby vmhonze repreunwtivesofthiscity ro enter upon the U 7a aMwe-memioned property far inspection purposes. ALTER OR ADD TO MEC(L. CONSTRUCTION TAX (We)agree to save,indemnify and keep lower...the City of Cupertino against liabilities.judgments,costs and expenses which may in any way seers,against said City AER HANDLING UNIT(TO 10.000 CFM) 11 a. fthe ger gof thio omit. /�o1D�9a AIRIIANDI.INGUNI'I'(OVER l0.q➢1CFM) Sfyllltu nr Applicm/Commcmr 11 ate E%l1AUSTHOOD(W/DUC v PAID HAZARDOUS MATERIALS DISCLOSURE HEAPING UNI'r(TO 100,000 BTU) D.1f,, Receipt IT Will the applicant or future building occupant store or handle hv.ardous mmerimd )iBATING UNIT(OVER 100,100 BED) 'TOTAL: as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety Code,Section 25532DI? �,/ VENTILATION PAN(SINGLE RIS)U) ❑Pas }y,Nt ISSUA/JCE DATE Will thea licwmr(fm_ure building occupant BOILIiR-COMP(JHP OR 10U,000 BTU) P' pp g pan quipmentnrdeviceswhich emit a1 �f huardes,air conmmine�msst(as defined by the Bay Area Air Quality Management BOILER 100,1100 BTU) �. Dlstrint? I JVOI1 TF1 ❑Yes No NEW RLSIDI?NTIALMECII. SQ,FT. 1992 I have read the lumaorous materials requirements under Chapter 6.95 of the - Cnliforniellwfh&Safely Cnd,,Sections 2550.5,25537 anA 25534. [undersumdthm CITY �f `Url.� if the building does not currently have a tenant,that it is my responsibility to notify the t l�occu m f the mquiremems which m t be met pnnr m issuance of e Ce 'true of amhonzed agem 11, at� TO'T'AL: ISSUED BY: OFFICE