26711 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY,OF CUPESION BUILDIN'.R PERMIT NO. r�
_ APPLICATION/PERMIT PLUMBING PRJECT IDHANIFIC G
BUILDING DIVISION � BUILDING PROIF.C9'IDF.NO'IM'ICA'1'ION
6711
BUILDING ADDDRESS: 10 ,3 SANITARY NO. APPLICATION SUBMITTAL DATH
4
A)a / "412,19/ `7 UNIT# LOT �i'r1iM
WNIBS NAME: PHONE: ' C ACTOR'S NAME: A LIC NO:
10A) U// S-S N/C CONTROL#
AR 'IT,
/ENGINEER: LIC NO: ADDRESS: /' JJ T ❑
CONTACT: PHONE: s A V q : #,& w -- --
C r a•r'.v P w '* a £s Z Y a# BUII]DING PERMIT INFO . -
QTY.. HLHCTRiPERMIT x PBC t
w, ). nB':#i13+eg 9:a 8'%;:"n Y` + r r•i',s BLDG ELECT PLUMB MF.CH
PERMIT ISSUANCE El❑
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIFIT
qaz Ih7000)affirmthat3 of th Bu under'and Proensocan,Code,and(commencing with
nzz Sectionhereby nfrmtht I nFlhesedarresand Profess jonsapter9(cmyhoeing I.with
pANp{,g -
g;UE muforeearm, t.
Fzm Licen c". eZD Lid.K -1 UP TO 201)AMPS
m O� Dad - Cm mcm,CLARATION `eAs r ,m)
201-1000IID.AMPS
,Z FO y ARCI{ITGCFB DEOVER IAMPS - SQ.Fr.FLOOR AREA $/SQ.FT.
oz-z IunderstandmypldTsAullbetacticspubliemorads. _
P rn I-J SIGNS ELECTRICAL
<;sE--I Lirwc dProfessional
P'y Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
�dF I hereby affirm that I am exempt from the Contractor's License Law for the
'3 0'5 mfollowing reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
❑u .] which requires n permit 0 construct.alter,immrove,demolish,or repair any structure
prior to its issuance,also requiew the applicant forsurh Permit o file a signed statement POWERDEVICES
yy O p That he is licensed Internet to the provisions of the Connector's License Law(Chapter 7-7 ,
e• ce 9(commencing with Section 7000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC _ r 1 ,� .�• VA TI
IN
µ),my or that bele exempt therefrom and the beets for the alleged exemption.Any vloletinn of /� r-� II p ^T fi^ 171
C Section than
bewydfulicam for$500).tsrhjeca the applleanuoacivil penalty a[ OUTLETS-SWITCHES-PIXTURES IP Ilhb✓✓II 101 Il',L.. IYe�6i
not more than five hundred dollars(85(10).
prop¢ y yemp y g p NF,W RESIDENTIAL ELECTR S .
❑do(he
w,k,.nde rt,onto er tinimehwn for
dei(See c0,1 1faireas Q S- TYPE. ONS'TRUCTION
L will dothewons aide-The mareiactors License Law does of apply to hir Business
and Professions Code:The Contractors License Law does not apply to do owner of I _
propreny who builds m improves thereon,and who does such work himself onhrough his
employeesilding ,ithne...dr improvemeithindre iearfidoallefim.forsale.If, OCC.GROUP RES.UNITS
bo lder wthebve the burden
of provinand issolde did noneyear or improve
purpose f TOTAL:
salerwill have the buNen of proving that he did not build or improve fur purpose of
sale) F'°ic r v r
QTY,r a„ ! PL BING PHRMIT-< a ApN
❑construct
the project
pro(Sec.70 Timex mess and
Professions
s C.—sedoontr1.. to a{-U i8 r 3 k* - { v. Ey y': PfAOD ZONE
License
the ocanot pply](144.Besmear end ywhobtons Cede:)The Cnnvremr's
LicenseLaw
cts Formica
whoscdpumtmprothe Coredgond PERMIT ISSUANCE
who
nseLactsforsuoh projects withawntractor(s)Ilcensedpurar.nttotheConwctor's ALTER lammw. WATER THAT `ia<y-r "PHH'SUMMARY
❑ I am exempt under Sec. ,B&P C for iM1is reawn BACK FLOW PROTECT.DEVICE O T OUR FEES
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA.COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ihemby alfrm that lhave acenificam of coater to eelFinsure,orncertificatc of FIXTURES-PER TRAP RECEIPT#
Workers'C�n9lmpen�sutiYee'syon(�l�neuranceoracenifiedcopy thereof(Sec.3g00,Lab CJwhich PARK FEE YN
role P01icyaI/ .LS7_r Ibis pgrm_t��/ GAS-EA.SYSTEM-I INC.40UTLETS RECEIPT#
/ Y BUILDING DIVISION FEES
Comoavrc{�'�'rC t„s,a GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
1-17 mfed copy is hereby furnefiW
❑ Certified copy is riled with The city inspection division. GREASRJNDUSTRL WASTE INTERCEPTOR
GRADING PEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need nmbn con lewd ifthe permit is forone hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY PEE
or less.)
Icenify that in the perfurnmer.Od work for which this permit is issued,Ishot] WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to become subject to the WorkersPAID
Compensationlxwsof Cnlifomte. Date WA1'ERSYSTIdvh REATING Date Receipt#
0 z Applicant
Z 0 NOTICE TO APPLICANT.If,after making this Cenifcam of Exemption,you should NEW RESIDENTIAL PLMIL SQ.Fr. TOTAL:
FV) become subject o the Workers Compensation provisions of the Labor Code,you most
forthwith comply with such provisions or this Permit shell be deemed revoked. BUILDING FEE
Lk1 [] CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that them is a construction lending agency for the performance of TOTAL: ELECT FEE
U O the work for which this permit is issued(Sec.3097,Civ.CJ
Lender¢Name - `'-C d a, s -;IaAEH a i: PLUMBING FEE
EI'AMEC�14E�ANJCAL
W F tenders Address QTYHANICAE PPRMIT )U 1 certfy that I have read this application and state that the above information to P4 t „_ s pa„„correct.1 agree to comply with all city and county ordinances Tied state laws relating to NCE �� MECHANICAL FEEbuilding construction,and hereby anthem representatives ofthiscity toenterupnn the
above-memionedpropmy for ispection pmposcs. TO NIECE. CONSTRUCTION TAX
(We)move tosave Indemnify and keep harmless Ne City of Cupertino.,.justIiibilities,judgmems,cosaandexpenuswhach ray inanywayaccrueaganstsaidCiry t, UNIT(T010,000 CFM) /a
in r. e of the gmmi sg of thin perms
AIR HANDLING UNIT(OVER 10,000 CPM)
Sig Iureof ApplicantiCommctor ��— EXHAUST HOOD(W/DUCT) _
PAID
HAZARDOUS MATERIALS DISCLOSURE It RATING UNIT(TO I00,000 BTU) , Date keceipt# '
Will the the Cupm or furore building de,Cam Blore or handle hazardous a d material
Code,
Section
the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000BTU) TOTAL:
Code Sermon 25532(e)Y
El Yes 0N VENTILATION FAN(SINGLERESID)
BOILER-COMP(3HP OR 100,000 B ISSUANCE DATE
Will pairhe contaminants
is an deifiedlding by the Bay Ana
Ai rt ordevye Manages which ment
Pf A
hartrict? air comaminants as defined by the Bay Area Air Quality Menngemem BOILEiR-COMP OVER 100,000 BTU) V'- /1
District? (
❑Yes ❑No NEW RESIDENTIAL.MECII. SQ,FL'. to Q �aa
L
have read the hactedous materials requirements under Chapter 6.95 of the JULV v JU
nia Health&Safety Code,Sectio94
ns 25505,25533 and 25534.1 understand that 1
uilding does not currently have a tenant,that h is my responsibility to notify the GIU�I Ur l,Uf R1it of the requirements which must be met prior 0 issuance of a Certificate of �ancy.orauthonmd agent Date 151 ISSUED BY: TIM
OFFFCE