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28262 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPFRTINO BUILOING-ELECTRICAL PLRMTr NO, 28262 �8 6 -/ /�/� BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL -/ BUILDING PROJECT IDENTIFICATLION lJ 6 L BUILDING ADDR[��IIS�S: � •� G' ^. \ `r SANI'I'ANY NO. APPLICATION gUBMITT/AL�DAT� 73 • I W • W ��I UNITp OTM r` OWNS S MF:: _ 4PI10NE: n CONTRACTORSNAME: LIC NO: NIC _CONTR�OLM J • ARCU .Cf/LNGINEIR: 1LIIICCNO; L+ CONTACT: PHONE: v / BUILDING PERMIT INFO QTY. ELECTRIC PERMIT FEE BLDG ELE PLUMB MECH PLRMITISSUANCEEl LICENSED CONTRACTOR'S DECLARATION APPLIANCES.RESIDENTIAL JOB DESCRIPTION elk q00 Ih7000fi lDivisarl amfthcBdunss and Profession. Code (it mmecense wish ti1w Sceioreand of DivisinnJofthe Rosiness end Professions Code,and my license is in PANELS FQ VVZ Lclenssee and q_ Lic.p C �'L' UPTO200AMPS / �`A\ F"a4 Date �s lam' Cunvuclor µ- 201-EM AMPS v (~ �o=nG ARCEITE=DECLARATION SQ.IT.FLOOR AREA $/SQ.Irl'. CZ 0 l understand my plans shall be used as public records. OVER 11100AMPS �w�.4s SIGNS RLEC3RICAL gg, ;; Licensed Professional "y`� OWNER-BUILDER DECIARATION SPECIAL CIRCUFUMISC. UiW�Oau 1 hereby affirm(be,1 am exempt Prom the Contractors License Law for the . .wa following mamn.(Secdcor 703 L5,Business and Financial.Code:Any city.,county TEMP.METER OR POLL'INS('. 11.1 which requires a permit to constmet,alcor,improve,demolish,or repair any structure W}2 priano its issuance,also mquiesthe applicant for such Penni,m file u signed statement POWER DEVICES K<O Nat he is licensed pursunnt m the provisions of the Comfort License Law(Chapter L Qo 9(commencing with Section 7")ofDivision J olthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION _ue or that lie is exempt therefrom and the basis for the alleged exemption.Any violation of OUTI.E'1'S-SWITCHES-FIXTURES tZQ Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of g0 not marc than five hundred dollars($500). NEW RESIDENTIAL I3LECfR _SQ.F1'. r©7 ❑ I,usowncrofthepmperty,orinyempinyeeswithwagcsastheirsoleeompen.sationy STORIES TYPE CONSTRUCTION a will do the work.und theiruaure is not imemdedoroffesal fornde(Sex.7044.Business and Professions Code:The Contractors License Law does not apply to an owner of I4 property who buildaor improvestheremn,and who due sauoft work hieselfarthmughhir OCC.GROUP NIiS.UNITSownemployetc,providedtha...olu mpowenentr arn emintenc dedoffered tarsale.If, however.the buildingmr improvement is sold withinmve yevro(completion.the owner- builder will have the burden of proving that he did not build or improve for purpose of solo.). ❑ I,mownerofthepmpeny,ameaclmivelycnmracdngwidlicensedemnuactorzto QTY. PLUMBING PERMIT FEE Fl. OD ZONE APN construct the project(Sec.70,Pt,Business and Professions Cole)The Contractors pFRMI'1'ISSUANCE License Lew does not app ly m on nwntt of property w ho b u ids or improves thereon,and who contracts fmauch pmjems with acontmnor(s)licensed pursuant m the Cmnrreaors License Law, ALTER-DRAIN As VENT-WATER(EA) FEE SUMMARY ❑ 1 um exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE: OUP DEP- SANITARY Y N Owner Date RECEIPTp • DRAINS-FLOOR,ROOF,AREA,COND. WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N ❑ ers'Co afPomthalhave ceoraccareof copytherof(Sarevent to nsum,m LahC.)whicte ofh FIXTURES-PER TRAP RECEIPTM Worked Compensation Insurance ore certified copy thereo!(Sac.Jg(gl,Leh CJ which PARK HE Y N Covers allmr n Fs a RECEIVp# Coversficy 5 GAS-IiA.SYSTEM-I INCA 0UTLE9'S BUILDING DIVISION FEES Company A4 - GAS-EA.SYSTEM-OVER 4 BQC PLANCHECK FEE ❑ CutifieJ copy is M1ercby tumrsbed. r�CenifiN copy is flat with the city inspection division. GREASEJINDUSTRL WASTE INTERCEPTOR GRADING HE CERTIFICATE OF EXEMPTION MOM WORKERS' .^a OREASPuT SOILS FEE COMPENSATION INSURANCE ,j,--�SC�` ' (7his section neeA nmndmmplemA ifthe r�StikufeE@feTumlru1'dllvrs($100) SEWER-gANITA V-STORM EA.200111'. ENERGY FEE others.) .. . I cenifytha math,pert eof the wor[fnr which this permit it iss.1,64 h BEAT ER not employ any person in as .mnnne so M m WON t t�the WNken PAID Compensation Lows of Cslifan Da �'^" 1-' SYSTEM/TREATING Date Receipt# ZZ Applicant P NOTICE TO APPLICANT:If.Alor making dip nifioetopf s ti m, ou h Id RESID A+.PLMB. SQ.ler. TOTAL: {—� to bacons,subject to the Worker's CnNpensnlion l�'/f`.�If;m alfJI ,yin st Fa' ; forthwith comply with such provisipns or this tahalRe domed BUILDING FEE W r' SEISMIC FET? Q CONS ION P.NDING Z (hereby affirm tha the iaa svu ndi gamey for the perfonnence of •u.4�, TOTAL: ELECIRICME the work far which this permit is is led(S J,Civ.C.) •CG •�'� U Leme,,Namo D" QTV, MECIIANICALPERMIT FEE PLUMBING IM.�" Lenders Addrtss -` U I comfy that I have read this appbc—.ntun and state that the above information is W correct,l agree to comply with all city and county ordinances and state laws relating in PERMIT ISSUANCE MECHANICAL FEF, building<onst on, hereby umhodze representatives of thisciy rococo,upon the above-meni nod props for inspcmion sea. ALTER OR ADD TO MECH. CONSTRUCTION TAX ��77 (Wej g"a'. e m euv,indemnify an ke p hnnnless @e City of Cupertino against liabilitiea,j nems misand peas aw nchmnyinanyweyacrueageinslsaid City AIR HANDLING UNIT(TO Moot CFM) conseque egmntin pe nit. AIR HANDLING UNIT(OVER 10,000 CEM) Signaum mf ApplicamiCmnwnor Dao EXIJAUST PIOOD(W/DUC l PAID I JAFARDOUS MATERIALS DISCLOSURE 111i"MING UNI'I(TO 101),0110 BIG) Date Receipl0 Will the applicant or future building occupant store or handle hazadous material HEATING UNIT(OVER 100,000 BTU) L as def red by the Cmisminm Municipal Code,Chapter 9.12,and the Health and Safety Code,Section 255321a)7 VENTILATION FAN(SINGLE RESID) ❑Yes ❑No -(y� ISS A OE DATE Will the aPPlicantarfururc buildingacupant uscryuipmenmrdcviaawhichcmit I BOILER-COMP(3HPOR 100,001013111) hazardous ah.conrnminwts as defimod by the Bay Amu Air Quality Management BOILER-COMP(OVER 100,(1(10 BTU) District'! / n ❑Yes ❑No NEW RESIDENTIAL MECH. SQ.PT. GJ�- 9 � `� 1 have read the hamrdnua nationals requirements under Chapter 6.95 of the California Health&Safety Cci[,Sections 25505.25533 and 25534. 1 understand that ' V if the building does not currently have a tenant,that it is my responsibility to notify the owcupam of the requircr ants which most be met prim m issuance of a CeniOcam of Occupancy. Owner unauthorized agent Dae ISSUED BY: OFFICE