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24636 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OFCUPERTINO BUILDIN -ELE. RICAL PERMIT NO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. A BUILDING PROJECT IDENTIFICAT4 ION 636 BUH DING ADDRESS: SANITARY NO. APPLICATION SUBMITTALDATE CM USTI# LO'I'N 0 LRS NAME: PHONE: C OR:9 NAME: LIC O: LSN/C COM ROLN RCHITECT NGINEER: LIC NO: ADDRESS: n ❑ OMACT: PHONE: (` BUILDING PERMIT INFO QTY. ELECTRIC PERMIT PEE BLDG VE MECH PERMIT ISSUANCE It ' Zo LICENSEE CONTRACTOR'S DECLARATION APPLIANCES-R S FNHALOB OPSCR ION Cyy IM1ereby of rre Thad am licensed under provisions of Chapm,9(commencing with �00 Sectfore000)of Division 3nf the Rosiness and Pm[sionsCWa and mylicenstix in PANELS C tv 1�F.. full force and of feat. FZ� License C • Lion UP 2 AMPS .<c. Data Crucial., 01 AMPS F,z ARCHITECTS DECLARA'HON R 1 b A P SQ.IT.FLOOR AREA bbQ.<T. ZOm— lundenlnnd myplansslmll be used us public records. OZ—C (ate <-5i SIGN .1 L be,, Licensed Professional K �Q OWNER-BUILDER DECLARATION SPE 1. CULT/MISC. LLy Ne. I hereby affirm Lha 1 min exempt from the Conlmetors Licorice Law G IM1e following reason.(Section 7031.5,Business and Professions Code:Any city meta my TFM .MIST ER OR TOLE INST. awhich requirts a penal to canstrma,ager,improve,demolish,m orpati!any sanctum ��T� priortoit issuance.also rcquires@e applicant for such pertniuofileasignW stat¢mem PO DEVICES COp that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter SWIMMING POOL ELECTRIC Ldp"' 9(mmmencing with Seclinn9000)nf sinn3 oRhc Business and Profcsaiem'CWc) VALUATION WM,n or that he is exempt therefrom and The basis for The alleged exemption.Any violation of IygyCpS-SWITCHES-FIXTURES (fir© 7� F Z Q Section 9031.5 by any applicant for a permit subjects the applicant to a civil penalty of _ 4 not ore than five hundred doll...(SSW). �! nd ❑mI,asownn edlhc,.enm y, ... rpmpyrpswithTI ,,lp,, dwirsoleccandemniom NEW RESIDENALELECR SQ.MI'. STORMS TYPECONSTRUCf10N W t: p-3°�° will dothework.end the sbunurc is not intended orofferedforsale(See.9044.Buslnes and Professions Cada The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or through his employees,provided that such improvements are not inteadedor mfferedforsale.If, OCC.GROUP EAIN however,the buudmgorimprovenowl is sold within one yew ofoompler^n,me owner- 4�� builder will have the burden of proving that he did not build or improve for purpose of sale')' QTY. PLUMBING PERMIT FEE PLUOU ZONE ❑ l,aso rofthepr^pony..mexclasivelyconractingwiNlicenaedcontmc.orsm mmmct thenryopro(Seo.9044,Bmincas and Profcsions Codicil h,Commit-, _ License Lawdoes not apply to anownerufproperty who buildsorimprovesdorenn,and PERMITISSUANCE ismOmtmrts fm suchprojccts wiNaconlmctor(s)licensed pursuant tothe Convactnr's ALTER-DRAIN&VENT-WATER(EA) License Law. �� PEE SUMMARY ❑ -1 am exempt under See. .13&P C for this reason BACK PLOW PROTECT.DEVICE OUTSIDE FEES SANITARY Y N Owner Date DRAINS- RECEIPT# WORKMAN COMPENSATION DECLARATION Fl.00R,ROOF,ARG,COND. SCHOOLTAX Y N ij IM1ereby affirm thatlhuvcacenificatc of consent to xlf-insurt,ora cenificae of FIXTURES-PER TRAP RECEIPTp Workers'Compensation Insurance or a certified copy thereafgtt.9g00,Loh C.)wM1ieh PARK FF.F. Y N rescriall employee's under this lxr tan. GAS-EA.SYSTEM-I INC.4 OUJ'LE.TS RECEIPT#' policy �� BUILDING DIVISION FEES Co ny GAS-EA.SYSTEM-OVER4F) PLANCHECK FTE U+O entified copy Le hereby furoished. Certified copy is filed with the city inspection Timmer, GREASIVINDUSTRL WASTE IN]P CEPTOR GRADING Fl.1. CERTIFICATE OF EXENIPTION FROM WORKERS' GREASETRAP SOILS FEE O COMPENSATION INSURANCE (fhisecmi^n n,dire he cnmplerd Dbe permit is l'orone hundred dollars IS 100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE �a less.) I mrtify Thm in the perfommnce of the work for which this penniYlIs 11 A RI E R� nm employ any person in any manner w az to become subject tb the id t a, PAID Co mpamatinnl..wsof Culirorma. Date 111111 WATERS STB'"EA Ume Receipt# z 'z Applicant I T.-. .. 0 NOTICE TO APPLICANT:If.after making this Cenifcae of Exemption,ykuu should NEW RPSi!)EN'1'IA.P tSQ.FT. l'O}'AL: (-' become subject to the Workers Compensation provisions ofthe Labor Code,you mon . a > forthwith comply with su.It provisien.on his peard,shall od deemed revoked. BUILDING FEE r-� V 1 Q CONSTRUCTION LENDING AGfiNa- CY SIiISMIC F1313 O IM1ereby affirm That hem is a construction lending agency for the performance of U 0 the work for which this TO ELECTRIC 113E Oslo permit is issued(Sm.3099,Civ.CJ Lender's Name u-' F Leaders Addrcs QTY. MECHANICAL PERMIT FEE PLUMBING FEE �. 0 U I certify that I have read this application and sour.hal rhe above information is MECHANICAL FEE �-' cored. lagrte mcomplY's'ith all city and county oNinances and state laws relining to PERMITISSUANCE �� F-' n' building connructim,and hercbyamhorize rcpreunmrivcwides city mecoutigonIM1e aMrve-mentioned pro"o,r t ALTER OR ADD TO MECH. CONSTAUCTLON TAX U Z We). to save.indemnifynand kecehamtles the Cit f Cupertino wa I �^ ( gree p Y u pe goons liebilities,judgmens.costxand expenuswhic may in env way acemeaganst said City AIR HANDLING UNIT(TO 10,pIXl CFM) inron. u ct gmml^ fthis pc 7 AIR HANDLING UNIT(OVER I0,0(I(I CFM) ignauure&ApplicanlCon coo L Date E- JAUS'1'1{OOD OVDUC9) - PAID H RDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Date Receipt# Will rbc applicant(IT finure building occupant store or handle hw.ardom material as defined by the Cupertino Municipal Cole,Chapter 9.12,and the Health and Sal cry I IEA'1'INC,UNIT(OVER 100,000 BTU) Code.Section 25512(a)? El Yes El No VENTILATION PAN(SINGLE RISID) G ISSUANCE DATE Willa applicant rfuuvcbuilJin tu.mc equipment BOILI3H-COMP(311Y OR Il%l,fk10 BTU) ITy n ' agoy the ympmen P A na mous air contaminwls as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER LOB."BTU) sarin? E)yes ❑No NEW RESIDENTIAL MECIL. SQ.FT. DEC IV[/1 9Q2 1Q I have mad the hazardous materials requirements under Chapter 6.95 of the •vV Cri fomia Health&Safety Code.Sections 25505,25533 and 25534. 1 understand Ihm Cl I Tyr Cuif,he building does a.cumemly have amount.Than it is my responsibilityto nmif dr, C occupant attic requirements which must he met prior m issuance of a Certificate of Occupancy. { T L Owner oruwhoriud agent Dam : ISSUED BYV—� 1x1 OFFICE