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25498 (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 25498 BUILDING DIVISION BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITTALDATF. UNIT# LOT ERS NAME: PHONE: AFNO N E' LIC NO: 70 4h.4.11NIC CONTROL# ARCHITECr/ GINEER: LIC NO: `7 ❑ , nit .3 S rnNTACT: PHONE: BUILDING PERMIT INFO �ly��{t QTY. ELECTRIC PERMIT FEE '�N�07 BL G ELECT PLUMB MUCH, PERMIT ISSUANCE ❑ El ❑ LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION Qwz Unuebyaffirn that lam liecivedunderprovismneof Chapter9(commencing with 4100 Section 7").f Division 3.f the Business and Professions Coda and my license is in PANELS C Z W full farce and effect. Fzm License Class Lic.# UP T02O0 AMPS `i5% Cmmxemr 201-1000 AMPS z8 n2 rrnn OVER IWO AMPS ARCHITECTS DECLARATION SQ.FT.FLOOR AREA I;/SQ.FT. 0Z_❑ 1 understood my pl...hall be used as public records. Fm W SIGNS ELECTRICAL ' LicensN Professional p OWNER-BUILDERDECLARATIONthe Co ATION SPECIAL CIRCUIT/MISC. pecx..O a F I hereby affirmand 1 am exempt from the Contractor's o License Law for the p+3�m fallowing reesoa(Seninn]03LS,Business and Rafeesione Code:Any city or county TEMP.METER OR POLF.INST. rn which requires E permit to construct,alter.improve,demolish,or repair any machine ti li-� prior to its issuance,also requires the applicam for such permit to file a signed statement POWER DEVICES 0.O�O the he is licensed pursuant m the provisions of the Contrectols License Law(Chapter %� 9(commencing with Section 701 of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATIq(�� WM,, or that he is exempt herefrom and the basis for the alleged exemption.Any violation of a Sectian]031.5 It any applicene fora permit subjects the applicant loacivil penalty of OUTLETS-SWITCHES-FIXTURES G not nal'than five hundreddollars($500). NEWRESIDTOTIALELECfR _SQ.FT. ❑ 1,asownereftheprnpen,,ormyemployeeswithwagesastheirsolecompemation, STORIES TYPE CONSTRUCTION will do the work,and the swcture isnot inteadedoroffered forsale(Sec.]0,VLBusiness and Professions Cole:The Contractor's License Law does not apply to an owner of property who bu i Ids or i mprov es thereon,and who does such work hi mself or through his wnemployees,provided that such improvememsure not intendedoroBered formle.If, OCC GROUP RES.UNITS however,the buildingor improvement is sold within one yearofcompletion,monomer. TOTAL: builder will have the burden of proving that he did not build or improve for purpose of sale.). ❑ I,as awnerofthe property,amexclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN remoter the prgecr(Sec.](laid,Business and Praressions Cade:)The Cohrmcmr's License Law does not apply to an ovaerofpropemy who builds or improves thereon,and PERMIT ISSUANCE whhcoutraces forsuchprcjects with acontramods)licensed pursuanttothe Convector's ALTER VENT- PEE SUMMARY License Law. WATER(EA) ❑ I nm exempt under Sec. ,B ffi P C for this reason BACK FLOW PROTECT.DEVICE r OUTSIDE FEES Owner Date VE N AR 10 DRAINS-FLOOR,JUDGE,AREA,COND. # WO I've DECLARATION S- N ❑ Thereby affirm, at ave a cenificate ofconsen roself-ins ure,craconiBcateof FIXTURES PER•fRAP p # Woders'Compensv ilnsumacemmor, lEcopytheseof(Sea3B00,Lab C)whielt I R E T �4 N rovers ell employ 'r tosser chis permi GAS-EA.SYSTEM-IINC.4OUTLETS I # Policy# ION FE S Co ny GAS-EA.SYSTEM-OVER4(EA) DATE Ce fi copy ie hereby um ani ted copy is filed ith the city inspection divi GREASWINDUSTRL WASTE INTERCEPTOR GRADING FEE CERTIFI TE OFEXEMPTION FROM WORKERS' GREASETRAP SOILS FEE OMPENSATION INSURANCE (This section need notbe completed ifthe pennitis farms hundred dollars($100) SEWER-SANITARY-STORM EA.20017. ENERGY FEE or lass.) I certify that in the performance of to work for which this permit is issued,I shall WATER HEATER W/VENT/ELECTR not employ eay person in any..act so as m became subject to the Workers' PAID z Compensation Laws of Califomin, Date WATER SYSTEM/TREATING Date Receipt# Applicant z NOTICE TO APPLICANT:If,after making this Cerificamof Exemption,you should NEW RESIDENTIAL PLMIU SQ.FT. TOTAL: 1-•s q] become subject 0 the Worker's Compensation prvono nsofthe tabor Code,you must �i 7 forthwith comply with such provisions or this pemdt shall be deemed revoked. BUILDING FEE [1a (] CONSTRUCTION LENDING AGENCY SEISMIC FEE z 1 hereby affirm that there is a constartim lending agency for the performance of TOTAL: ELECTRIC FEE O Ne work for which this permit is issued(Sec.3097.Civ.CJ Lender's Name ULender's Address QTY. MECHANICAL PERMIT AEE PLUMBING FEE LTI 1 certify tltat 1 have real this application and state that the above information is (]. amuct.I agree m comply with Ell city and county ordinances and state laws relating to PERMIT ISSUANCE MECIANICALFEE rA buildingcomm"ll ,and hereby authorize representatives ofthis city theater upon the V z above-me dome party for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX ^� (We)u m save,indemnify and kee ess the City of Cupertino against liubiliti gments,costs end experee may in my way accrueagainstmid City AIR HANDLING UNIT(TO 10,O0s,CFM) in coVae cc or the grating of trait. ail Iq AIR HANDLING UNIT(OVER 10,000 CFM) tureo Applicant/ an m ate EXHAUST HOOD(W/DUCD PAID AZA RDOUSMATERIA DIS ISOM HEATING UNIT(TO IOQOOO BTU) Date Receipt# Will the Epp am or future building men a re or handle hazardous molal HEATING UNIT(OVER 1 W,OPq BTU) TOT L: as definedCupertino by the Municipal Code,Chapter 9.12.and the Health and fiery Code,Section 25532(E)? ❑Yes ❑No VENTILATION FAN(SINGLE RESID) Will then licanmrfmure buildin BOILER-COME(3HP OR 100,000 BTU) ISSUANCE DATE PP d by the Day Area enmuality Management hazardous air Comaminants as defined by the Bey Area Air Quality Management BOILER-COME(OVER 100,000 BTU) R7 p ' D District? Y' P1 ❑Yee ❑No NEW RESIDENTIAL MECH. SQ.IT. 2 I have read the hazardous materials requirements under Chapter 6.95 of the AUG "- 6 1993 Cdifomin Healtha,Safety Code,Sections 25505,25533 and 25534. 1 understand Nat if the building dces not currently have a tenant/that it is my responsibility to notify the occupant of the requiremems which must be met prim m issuance of a cenificate of CI I I VH V ur 1� Occupancy. Owner or amhorims!agent Dam TOTAL: ISSUED BY' OFFICE