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28219 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUH,DIN'c ELECTRICAL PERMIT NO. BUILDING DIVISION APPLICATION/PERMIT PCOMBINC MECHANICAL (�O BUILDING PROJECT IDENTIFICATION G o G 19 BUILDING ADDRESS: ^ ,rte SANITARY NO, APPLICATION SUBMITTAL DATE j, U Q� o C y, .UNIT# L T# OWNERS NAME: PHONE: CONT CTOR'$NAMB: TLf'2da�-. JCNO:(�� CZ 4_,V �_7 � 05, we coNTROL# �ARCIIITECT/ENGINEER: LIC NO. ADDRESS: EJ CONTACT: PHONE: '7 �j / QTY. - " ELECTRIC PERMIT FEE - BUILDING PERMIT UM MPO 060,1 Pal P-XP 1 2 �U �a © PERMIT ISSUANCE BLDG MECH LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION El a!mz I hcbbyafRthat lam liwnsed unduprovislons of Chaptu9(commencingwim rm 00 Sermon 9000)nf Division Sof the Business.std Professions Code,and any license is in PANELS IdE fall nseeand effect, / y� pu License Cl s` Lie. 6 UP T02W AMPS mu ae Dom Corroder 201-I WO AMPS ZONZL, ARCHITECTS DECLARATION OVER 1000 AMPS SQ.PT.FLOOR AREA $/SQ,Up. O Z—❑ I understand my plans shall be used as public records. SIGNS ELECTRICAL ,,....I1 LicensedRnfeoional �m�m< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. �JOp,F 1 hereby affirm that Imp exempt Enrollee Commends License Law for the W 3 wap fiedicovwhich oppore,is per cit m o 31.S,Businessmpr Professions lU.,re ai city stratum a um TEMP.MFTF.R OR POLE INST. E'op Oro; whichitsissuaeermB reveres thealter,improve,demolish,firepair anysauewrc r°Y�. pdormirsies edpursunttothn thevisios ofor thsuch Co perdue License La s(atwtent POWER DEVICES pl cry 0pC that hem lrcialwpunuanln00)of Division the Corroders and pee Law(Chapter aW so 9 that hendxempt therefrom and the Division Sof llleedopssand.Any iota Code) SWIMMING POOL ELECTRIC VALUATION ly.,y onhathei31.5 by ttherefromende.lecos for the allegedexemant to Any violation of OUTLE'T'S-SWITCHES-FIXTURES p. d Section than 6e any hundrddollrs($10rmitmbjeoLstheappliaan[lnaeivilpcnalryof �� S - not more than five hundred dollars yemp. NEW RESIDENTIAL ELECTR _SQ.FT. OR ❑ I,the work,andeestructy,ormyemployedorrofcoolsasthei(sole corpensiness STORIES TYPE CONS'1'RUCTION m will dothewons andthat ire Contrature is ctor x License apply to Business and Professions Cade:The es ttrector's License Lew dress not apply to an owner of propwywyeti,pdsodmproveschimpr,andwhadoensuch wded.r ffeed hmughhis wnemployees,providul thatnaohimprovementsare not ivtended ornffuW lorsale.If, I OCC.GROUP RES.UNITS however,the bnildingorimprovement is sold within one yearofcompletion,thr ,invor- TOT builder will have the burden of proving that he did not build or improve for purpose of sale.). EI 1,asoro ster oftheppeny,am exclusively contracting with licensed contractors to QTY.' `PLUMBING PERMIT- FEE FLOOD ZONE, APN monad the project(Sec.9044,Business and Professions Code:)'Me Contractor's PERMIT ISSUANCE License Lewdoes not apply to an ownerofproperty who builds crimprovcomencon,and who contracts for such projects with a contracror(e)licensed pursuant to the Contractor's ALTER EA FEE SUMMARY License Law. ( ) ❑ 1 am exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT,DEVICE OUTSIDE FEES SANITARY Y N Owner Dare DRAINS-FLOOR,ROOF,AR OND. RF,CEIPT# WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN ❑ Iherebyaffirrtheill.ave acenifcatc of censer to self-insure,ora cenifcate of RECEIPT'# FIXTURES-PER TRA Worker.'employCompensationler this ermit. feed copy thuwf(Soc.38W,Leh CJ which PARK PEE Y N coven all employee's under this pemtitGAS 'fGM-I 1NC.40UTLF.TS RECEIPT# Policy# BUILDING DIVISION FEES Company tfAS-EA.SYSTEM-OVER 4(EA) PLANCHECK PEE ❑ Cenifaten,yisherebyfcirshed. ❑ Certified copy is filed with the city inspection division, GRGSMNDUSTRLWAST'EINT CEPTOR GRADING FEE CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE COMPENSATION INSURANCE -(This section need not be completed ifthe permit is for one hundred dollars($100) EWER-SANITARY-ST EA,2WFT. ENERGY FEE - orlese.) I eenit'ythm In the perfmmanceoC the work for wlinh,his permit is issued,[,hall ATER HES /BLEC not employ any paavn in any manner so as to become subject to the WorkersPAID mimore1tua Lawsof Califomla. Dote ATER S AREA O z Aitiffivem _X Datecele z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should N W E IAL MB. S TOTAL: become subject to the Worker's Compensation provisions of dm Labor Code,youmust � ; forthwith comply with such pmvisiom inthis pumh shall be deemedrevoked. BUILDING FBB f Slat CONSTRUCTION LENDING AGENCY SEISMI z I frrehyaffimflou is.lee consuuction lendingagwey for theperompammof .B the wn k far which this puri,is oared(See 3099,Civ.C.) BLHCTR ./ Lend N e PLUMBINO PEE Q U Lend Address QTY. a [GAL PERMIT, t"IrEE= I c t fy that I have read this application and nate that the above information is 7` a correct.lagrce mcomply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FE GA construction,and hereby authorize representatives ofthis city apparel upon the CONSTRUCTION AX U 4 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. ( e)agree m save,Indemnify and keep harmlus the City of Caper inc against liabili e,judgmwts,costa and expenses which may in.1 way awrucagainst said City AIR HANDLING UNIT(1-010,OIXl CPM) Inco se ueneeof the granting frhis poor. AIR HANDLING UNIT(OVER 10,D)f1 CFM) G- 70 fAfuldlibran/Cmunwort Date ' ESTAUSTHOOD(W/DUCT) PAID HAZARDOUS MATERIALS DISCLOSURE HEAPINO UNIT(TO 1010,00❑BTU) Dale Rece' t# Will the applicant or future building compar store or handle hazardous material as defined by the CupeOno Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IW,❑W BTU) '1'A Code,Sectio 25532(x)4 11 Yes 11 No VENTILATION PAN(SINGLE RESID) Will the spplleanmr[umrcbuilding nccupantuueyuipmenmrdoviees wM1lehemit BOILER-COME(SHE OR 1010,010 BTU) ISSUANCVADATE hazardous air contaminants as defined by the Bay Area Air Quality Management ietrin? BOILER-COMP(OVER 100,000 BTU)❑ e D _ Yes ❑No NEW RESIDENTIAL MECH. ^ A SQ.FT. I� I have read the hazardous materials requirements under Chapter 6.95 of the California llcohh&Safety Code,Sections 25505,25533 and 25534. 1 understand that lots. 19 if the huilJing does not curtently haveamnunt,that it is my respnnsihility to notify the (JIM ccupem of the requircmwn which must be mw prior m rssuunee of a Certificate of /� Occupancy. Owner or authorized agent Date TOTAL: ISSUED BY: OFFICE