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21667 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE ALL POINT PEN ONLY HildiriR Ad Bg Ildln Pm act Id atlon� / f PERMIT NO. 1667 0. dleV Mr©© e: CITY OF CUPERTTNd BUILDING DIVISION I ora f C ' �I=,?aa: APPLICATION /.PERMIT CATEGORY coNTRDL« Y BURAINGELECTRICAI.PLUMBINC-MECHANICAL mhltM/Engineer. Llc.No: .- _ QTY ELECTRIC PERMIT- FEE BUILDING PERMIT INFO' Address: PERMITISSUANC'E [j E] ❑ �ICYI LICENSED CONTRACTOR'S DECLARATION u Ihereby,7io irmthat taco licensed under provisions of Chapler9(commmc- APPLIANCES-RESIDENTIAL - JOB DFSCRBTION IngwlthSeaton f Wgon3ofthe8 nessand P�ofesai Codeguln License le In ofea. / (/' PANELS Licen Cls Lk.« ! N M e(7 Date Conhactor - "/ LI1 IQ IM AWS RCHITECTSD ION / 201-1000 AMPS 9 0 Z I understand p ns shag be used as public records. OVER IODO AMPS SQ.Fr.FLOOR AREA S/SQ.Fr. Iz Licensed Profeaslonal `ELECTRICAL ._ aysgy/-� 6 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/M15C j v i'�\ F ® a y YI Iherebyaf@mthallamexemptfromthe Cont moors Li...Lawlor the Y V Zo followingreason.(Se Hon 7WIS,Busl...Od Profession.Cade:Any city or O Z•" TEMP.MEFWi OR POLE NSf. I� cauntywhich requires.permittoconstroa,strep lmprove,demol6h,orrepair � I` �p .Sn anystruaure priorto its lssuance,atso requbeatheappBcentfor ouch permit to '-+✓ S 0k a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES. Owl ContraRoe.LicenseLaw(Chapter 9(commencing with Section 7000)of Divi- VA UATION f,3p`a gon3oftheBusnmandPro(emloruCode)orthatheisexemptiherefromand SWQdtANOPOOL ELE C DATE the basis for the alleged exemption. Any violation of Seaton 70131.5 by any < appEwntforapemdl.ubjeastheapplicanttoacivllpemltyofea ..than OUTLETSSWI7CFIESFLYI'URES five F]1,asrewnerof thepr). NEW RESIDENTIAL ELECTR SQ.FE. STORIES TYPE CONSTRICTION I,as owner LI the property,or my employees with wage a thele woe compensation,044,wBldmhe wori�..d Pr ndthe structure h.not Contractor o scene offered Law q sale(Sec.70fy Business and Professions Code:The Contraaat'e License Law does not apply to an owner of property who builds or improve thereon,and WC GROUP —RIS UNITS 1 whodoessuchwark Mmselforthrough Msmvnemployaes,provided that such Improvements arena intended proffered forsele.If,however thebullding or TOTAL; Improvement 6sold withinoneyearofcompletioNthe owner-bullderwlll have . .. ' I eft rden of proving that he did not build or Improve for se of sale.). ;7" `i•""I EE FLOOD ZONE -- APN u P g P purpose QTY. . PCUh1BING'I'ERMIT:"`' L as owner of the property,(m exclusively Business and ro with Brooded PERMIT ISSUANCE contractors to construct thew doe(Sec.apply to an and Pf property Code: The Contractor's impr'a License Lew does not apply tc sn owner of property who ALTER-DRAIN k VENT-WATER(FA) Wilds or Improves thereon, and who metrass for each projects with a cgB((bamexmpt underP.OumOt Sm the ContractorsLlces PLaw. - FEE'SUI1414fARY L.J I em exempt under Sec B 6 P C for this mason BACK FLOW PROTECT.DEVICE DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y_ N_ Owner Date . RECEIPTN WORgNAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y N []I hereby arffirmimm That I have• I ntifkate of consent to elf-insure,ora RECEBT« 3901),Laeof Worken'Gomperuallonlreumou"O certif�on I ereo((Sec. GAS EA.SYSTEM-1 INC4 OUTLETS PARR FEE Y N 380),Lab C.) 4;! (%I Ibliry« Ed I Dg RECEIPT« CoCertiBedropy6hercbylumishe ������mppppppany- � BUILDING DI VISION PEGS - � 1VINDUSTRI,WASTE INTERCEPTOR PLANCHECK FEE CcAlBed copy 6 filed with the cityd. mCAS EA.SYSTEM-OVER 4(EA)' i s onY CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASE TRAP PAID COMPENSATION INSURANCE (FMSEWERSANITARYSTORM EA 200PT Date Reeel IN ssealon need not be completed lithe pemdt 6(orom hundred dollars (5100)or lay.) WATER FiE47FR W/VENT/ELCCTR ENERGY FEE Y N I certify that In the performance of thewmic forwhich this permit is issued, ..- I shall not employ any person In any manner w as to become subkci to the WATER SYSTEM/TREATING Workrm'Compensrtioo Lawsof Callfom6.Date PAID Z Z Applicant Date Reeei [p Z O NOTICE TO APPLICANT:10ftcr making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQXT, I" should become subject to the Worker'Compensation provisions of the Labor TOTAL: CCN Code,you must forthwith comply with such proisimu or this permits hall be B ••E deemed voked. LU reCONSTRUCTION LENDING AGENCY SEISMIC FEE I hambyaffirmthat there Is a construction lending agency forthe perform ELECTRIC FEE O anmoftheworkfct which this permit 66vred(Sec.309'/,Civ.C.) TOTAT. ELECTRIC EEE V Lenders Name u. Lender.Addreaa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE O W Imrtlfythatlhavemadthieappllcattonand gate lhattheaboveinformstlon IL ismriect.I agree to comply with all city and county ordinances and gate laws PERMIT ISSUANCE dw �• F E$PAI (I) relating to building comtru,tion,and hereby authorize representatives ofthls F Z city to enter upon the abovcmmIkmxd property for inspection purposes. ALTER OR ADD TO MECH. Dale R — (We)agree to save,Indemnify an d keep harmless the City of Cupertino P against liabilities,judgments,cosmand expenses which may In any way accrueAIR HANDLING UNIT(T010,000 CFM) S . SUBTOTAL71 .• against said City in consequence of the granting of this permit. AIRHANDLINGIIIN'T'(OVERIBOOOCFM) CONSTRUCTION TAX Signatureof Applicant/Contractor Date IXTIAUS"r HOOD(W/DICT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) mater6 l as de0ned by the Cupertl no Municipal Code,Chapter 9.12,and the Date Reeei tit Health and Safety Cade Se tion 25532(a)7 HEATING UNIT(OVER 10),000 BTU) TOTAL: (-1 Yes MN. ILII appliranl or(umre building occupant use equipment or devices VENDLAT'ION FAN(SINGLE RESID) ISSUANCE DATE which e havrdoua air ronlamlmnts as deBMd by the Bay Arca Air alit nagement District? BOILER-COMP OHPOR IOQO(U BTU) JNo v ad the haze o marials requirements under Chapter 6,95 of BOILER-COMP(OVPR100,0WIVID) th Ia I hash &$a C e,Sect lore 25505,25S33 and 25534. I 1991 un rsta that if the bu din d snot ntly hale atenaot,thatltismy NEW RESIDENTIAL MEIN. SQ.IT n� A, !. BUY to notiffyy) pest of th rryulre to which must be p or I u.Nm Ts Ifl a O ^ er ar au n Datf IffiUED 'I �fL In TOTAL: ( OFFICE COPY