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25416 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY ON CUPERT[NO RUIL - .E.F.. RICA[. PERMIT NO. BUILDING DIVISION APPLICATION/PERMIT PLUM BING- NTiFIMECHANICAL 2 5 /I 'I 6 I1I111.DING PIt(/dKCI'II/P,N'fIPiL'A'1'TOry J L� 1 BUILDING ADDRESS: I �s�y� n SANITARY NO. APPLICAA [O`N^SJUBTE SUBMITTAL DA LI{aY UNITN LOT# 0 5 N E:— ! i/ PHONE: CONTRACfOR' AME: LIC NO: VVV 1!`/^(��1x g/L✓. N/C CONTROLN ARCHITECTA NGINEER: LICNO: A)DRP .Lt So - ❑ 'OHTACT: PHONE: BUILDING PERMIT INFO QTY. ELECTRIC PERMIT FEE BLDG ElyMECII PERMIT ISSUANCE .6 U B ❑ LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL. 0WZ I hereby affirm that l am licensed under provisions of Chapter9(commencing with JOB DESCRII9'ION til 00 Section Tf10d of Division 3.f the Business and Profevione Code,and my license is in PANELS ^ /� fall form,candoffcm. Di<c. License Clan Lic.N UP T0200 AMPS 1 V Vet M6 Date Can,. 201-1(100 AMPS FPy ARCUITf=S DGCLARAI ION SQ.IT.FLOOR AREA E/SQ.FT. ZOvNi� OVER IBfAT AMPS OZ-'q lunderswnd my plans shall he used as public records. p I� � rrn SIGNS ELECTRICAL ' � - 11 � © f N qa ,� Licensed Professional II V CG�yF OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. + 7, R �xx'OyU 1 hereby affirm Nat 1 em exempt from the Crmboetors Limnm law for the r W 3 tri y following matin.(Section 7031.5,Business and Professions Code:Any citym count, TEMP.METER OR POLE INST. q�' J I,to which requires a Permit m consruat,cher,improve,demolish,m repair any swcmrc KAK;!1,>i� prion.its inammce,ulso requires the applicant for such permit to rile usigned statement POWER DEVICES v VVV to a�00z that he is licensed pursuant online provisions ofthe Contractor's License Law(Chapter dao 9(commrncing with Section T(100)of Division3of the Business erM Rvfemiona Code) SWIMMING POOL ELECTRIC VALUATION �y or Nat he is ratings herchant it the basis basic alleged exemption.Any violation of OUTLETS-SWITCHES-Fl%TURFS ZQ Section]031.3 by any applimm,fare permit subjects themplicant to.civil penalryof A not more than Eve headrest dollen(5500). NEW RF.SIDIJJTIAL ELGCI'It o ❑ Lasawnerollhepropeny,ormyemployees with wagesastheirsolecompensation, —SQ.Icl'. STORIES TVPECONS'I'RUCION dnthewon,and Ne he Contisnmintendede Lawredes a., an Business oast Professions Cede:The Contractor's License Law does nm apply to an owner of own propertywhew,IJ sorimprovnchcmonaermar. aeaauchwart himmlfur Nmugb hie dMthvt such ire OCC.GROUP RES.UNITS howemployebuildi vi Pmvementhin not earacdmaffercd for mlalL however,the building burden of,mentis sold within one year or improve omm a for the owner- TOTAL: builder wit l have the harden of proving that he did not build or improve for puryom of rade), t ❑ I,us owner of Ne propcny,am exclusively<anreming with licensed contrmmrsm QTY. PLUMBING PERMIT FEE FLOODZONE AI'N construct the project(Sec.1014,Business and Professions Cotler)The Commiserates PERMIT ISSUANCE License lawdnes not applyto snownerofoomeny who builds or improves themeon,and whocoutmco for suchpmje to with Recommends)licensed pursuant to Ne Contractors License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY C] 1 am exempt under Sec. ,B&P C for this reason BACK FI.OW PROTECT.DEVICE OUISIDEFERS SANITARY V N Owner RECEIPT'q WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,BOOP,AREA,COND. SCHOOL TAX Y N ❑ I hereby uffirm that l have a cenificem ofcommrdna self-insum,or a cenificmeof RECEIPT# W.Arm'Cam FlXTIIRfS-PP.R TRAP prnsationimumnce ore certified copy thcrmf(Sec.Jg00.Lob CJ which PARK EEE Y N r covemallernt.yee'sundrelhis permit. GAS-EA.SYSTEM-I INC.4OUTI.ETS RECEIPT Policy N BUILDING DIVISION FEES Company - GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE ❑ Certified copy ishemby furnished. ❑ Certified copy is filed with the city inspection division. GREASEIINDUSTRIL WASTE INTERCEPTOR GRADING FEE CERTIFICATE OIs EXEMPTION FROM WORKL'RS' GREASE TRAP SOILS FEE COMPENSATION INSURANCE (This section need net be completed ifthe Period is far ane hualmildollur(5100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE or less.) I ccnify that in Ne performance of the work for which this permit is Tai l shall WATER HEATER W/VENT/HLECTR not employ my person in any mummer so as to become subject to the WorkersPAID Compensationlawsof California. Date WATER SYSTENYTREATING Data Receipt# Oz Applicant Z 2 NOTICE,TO APPLICANT ILaOer,making this Cmifieamaf Exempti......ahould NEW RESIDENTIAL PLMB, SQ.FT. TOTAL: Fr'. become subject to the Worker'a Compensation provisions of the Labor Code,you must > forthwith comply with such provisions car this permit shall be deemed mvoked. BUILDINGFEC W (] CONSTRUCTION LENDING AGENCY SEISMIC FEE z 1 hereby affirm Net there is a construction lending agency for the performance of TA ELECTRICME O the walk far which this permit is issued(See3097,Civ.CJ 14. r-t Lcade's Name t PLUMBING PEE O U Lenders Address QTY. MECI IANICAL PERMIT FEE I certify that 1 have read this application and more that Ne above information is correct.l agree to comply with all city and county arhrournw and sate Iowa relating to PERMIT ISSUANCE MECHANICAL FEE UF-' building mnswction,and hereby cathedra repmscnotivesofthiscity memerupon Has, CONSTRUCTION TAX 7 above- ianed propmy for inspection puryoms. ALTER OR ADD TO MECH. G (We) gree to save,indemnify and keep harmless the City of Cupertino against abilii ,' figments,cos nJ expenses hmay in any waymcrveugei st said it, AIR HANDLING UNIT(TO 10,"CFM) c m encs-ol th ming i. Imo. AIR HANDLING UNIT(OVER 10,000CFM) gnature of ApPlican4Cmunicmr EXHAUST HOOD(W/DUC) PAID HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,00(1 BTU) Data Receipt# Will the applicant or future building occupant sum or handle hmmdous material HEATING UNIT(OVER U10,000 BTU) TO as defined by the Cupertino Municipal Cade,Chapter 9.L!,and the Health and Safety Code,Section 25532(a)? VENTILATION FAN(SINGLE RESID) ❑Yea ❑No BOILER-COMP(3HP OR IW,(M BTU) ISSUANCE ATE Will theapplicantarfumrc buildingaccupint use equipmemordevica which emit p�j p loamdaus air contaminants as defined by the Buy Arca Air Quality Management BOILER-COMP(OVER 101.000 BTU) IP AID District? ❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT. 1 have mad the hazardous materials rapi m o ms under Chapter 6.95 of the AUS 2 51993 California Health&Safety Code,Sections 25505,25533 and 23534.1 understand that if the building does not c ntendy have a mount,that it is my responsibility to notify the �'I Y occupant of the requirements which must he met prior m issuance of a Certificate of Vrr\wrrrt III HVV Occupancy. �/ ✓d/� Owner or emhorired agent Date TOTAL: ISSUED BY: