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27116 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY CITY OFCUPERTINO HURANINU - KLEU ''RICAL BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL BUILDING PROJECT IDEN'FIFICA'I ION PERMIT NO. 27116 BUILDING ADDRFSS: SANITARY NO. APPLICATION SUBMITTAL DATE. 1) 9/ o WI I)OwJeff OJk wski LOTH Q-6 — / OWNERS NAME:: PHONE: CUM 'N CTO�fS NAME: / a LIC NO: BIC ❑ CONTROLN � ARCIII'T[ 7 ENG[ :ER: LIC NO: ADDRESS: a �� CONTACT PHONE: QTY. ELECTRIC PERMIT PEE BUILDING PEI PLUM INFO SLUG IiLCCI' PLUMB MECN ❑ ❑ ❑ — 610 -To e-5467-63 PERMIT ISSUANCE LICENSED CONTRACTORS DECLARATION 1 hereby affirm Net I an licensed under provisionsofChapter9(commencingwith Section 70(10) of Division 3 of the Business and Professions Code, and my license is in full farce and effect. g� License class C —; !O Lia. p Data Conwcmr APPLIANCES -RPSIDP.NTIAL PANELS UP TO JOB DESCRIPTION JAS" • k Ct A S ' I ll't rOAL 201 - 1000 AMPS ARCHITECTS DF.CII. ATI 1 undersumd my plans shall he used as put m records. OVER IOOOAMPS SQ.fT. .00H AREA S/SQ. FT. SIGNS ELECTRICAL Licenu l Pmfcssional OWNER -BUILDER DECLARATION SPECIAL CIRCUIT/MISC. 1 hereby affirm that I am exempt from the Contrucm's License Law for the TEMP. METER OR POLE INST. following moserm(Section 7031,5, Business and Professions Code: Any city or county which requires a permit to construct, altar, improve, demolish, or repair any structure Prior its its issaence, alstmmquires the applicant for such Permit o file asigned statement POWER DEVICES that he is license pursue..m the provisions of the Contra mir's License Law (Chapter 9(commercing with Section 7000) of Division 3 of0e Business and Professions Cee) SWIMMING POOL ELECTRIC VALUATION or Nat he is exempt therefrom and the basis for alleged exemption. Any violation of Section 7031.5 by any applicant for a Permit subjects the applicantto a civil poultry of OUTLGI'S-SWITCH[S -FIXTURES nm more than five hundred dollms($5WL CII,esmwmero(Neproperty,rnmycmPloyecswiN wag[sus th[irsolecampensatimn, NEW RESIDENTIAL ELIiCTR _SQ.IT. STORITYPE ON'TRUCDON will do the work.and the structure is not intended oroffere forsale(Sec. 7044. Business and professions Cade: The Contractor's License Law does not apply m an owner of propertywhobuildsorlmprovosthemon,and whodoessuch work himselforderoughhis own employees, convicted that such improvements arc itn not endked or offered forma. If, OCC. ROUP RES. UNITS TOTAL: hrtweve, the building or improvement is sold within One yearofoomplmns., theowner- builder. will have the burden of proving that he did not build or improve fm purpose of QTY. PLUMBING PERMIT FEE le.). ❑ I, irsowner mfthc crop[ny,emexclusivelyconwaing with littrtsedwnwctnmm F.00DZONE A conswct the project (Sec. 7044,wn oBusiness and Professions Cade:) The Contractor's License Law does not apply tom who buildsor improveathereon,and PERMIT ISSUANCE who contracts frrsuch projects with a cmttracmr(0 licensed pursuantothe Conmictufs License Law. ALTER (PA) FEES ARY ❑ 1 am exempt under Sec. , B & PC for this reason BACK FLOW PROTECT. DEVICE Out :1' E /V I SITARY N )k ILE ECI,IPTis Owner Data DRAINS -Fl.00R,ROOF, AREA,COND. WORKMAN COMPENSATION DECLARATION CI TOOL TAX ❑ I hereby affrmthat l have arciificate ofemocid toulf-insure,oraceAficareof Workers' Compensation Imutance or ecmifiewpY thereof (Sa.38p1, Lnb CJ which .CF.IITp FIXTURES - PER TRAP PARK FEE a a 11 employee's undenhis commit Iblicya b' s CAS-EA.SVSTEM-1 INC.40UTLEfS �� 1: :IPfN BUILDING IhNWISION FEIS Company CLI !Y' GAS- EA. SYSTEM OVER 4(EA) PIANCHI3C ' ❑ Ceniped copy is hereby famished. Certified copy is filed with the city inspection division. GREASE/INDUSTRL WAS TE INTERCEPTOR GRADING FEE C17RI'INCAI'E OF EXEMPTION MOM WORKERS' COMPENSATION INSURANCE SOILS ILE GREASBTRAP SEWER - SANITARY - STORM I'A. 200FT. KNERGY FEE ('mir union at not hecomp[cted ifthe permit is forma, hundred dollars (SIM) ism.) WATER IIEA'fER W/VFNT/ELECIR I certify that in the performance ofma work for which this Permit is issued, I shut[ not employ any person in any manner so as to become subject to the Workers' Compensationlawsof CLlifomia. Dam Applicant WATER SYSTEM/IRPATINO PAID Dam Receipts NOTICETO APPLICANT: If, eo, making this Cettificteof Exemption, youshmuld became subject to the Worker's Compensation provisions of the Labor Code, you must NEW RESIDENTIAL PLMB. SQ. FT. TOTAL: forthwith comply with such provisions or this Permit shall he deemed revoke. BUILDING FEE SEISMIC FEE CONSTRUCTION LENDING AGENCY I hereby affirm that them iso construction lending agency home performance of ELECTRIC FEE the work for which this permit is issued (Sec. 3097. Civ. C.) Lender's Name Lenders Address QTY, MECIIANICALPERMIT FEE PLUMBING FEF. 1 certify that 1 have read this application und smte that the above information is correct, lagrtemcomplywithnllcityundcountyordi ... cos und state laws achuing to PERMIT ISSUANCE MECHANICAL FEE building convection, and hereby aultorize repres¢na Lives colds city menter upon the also c -mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX (We) agree to save, indemnify and keep harmless the City of Cupertino against l inbilities,judgmems, costs and expenses which yin any way accrue against said City in consequence of 1M1e granting of Ni iia t pb/LA AIR I IANDLING UNIT (TO 10,00) CFM) AIR HANDLING UNIT (OVER Il" CFM7 marc Applicant/Commute, Dee EXHAUST HOOD(W/DUC) PAID HEATING UNIT (TO 100,ODO BTU) HAZARDOUS MATERIALS DISCLOSURE Dam Receipt a Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Cale, Chapter 9.12, and the Health and Safety I[RATING UNIT(OVER 100,0(0 BTU) TOT Code, Section 25532(2)'1 ❑ Yes ❑ No VEITHLATION FAN (SINGLE RFSID) BOILER- COMP QHP OR I W." BTU) ISSUANCE DATE _ Will thea licumor future buitdin ocev pp g pantuuequipmenmrdevicn which emit Wous air contaminants m defined by the Bay Area AG Quality Management Cami lcl'! BOILER - COMP(OVER 100,000 BTU) Ct ❑ Yes ❑ No -6 (' 1994 NEW RESIDENAL. MEC11. TI SQ. FT. 1 have rtad the hard zamm materials requirements under Chapter 6.95 of the Cir r L/f California Health & Safety Code, Sections 25505, 25533 and 25534, l undentand that if the building does not asthe that itis myresponsibility tenotify flue V dr mCarmody ts whave occupant of In, requirements which must he and prior m issuance of a Certificate of Occupancy. ISSUED BY: Owner or authmicim ¢gem Dam TOTAL: OFFICE