26768 T _ .
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPER'PINO BUILDING-LL C'TRI AI, PERMIT NO.
BUILDING DIVISION, APPLICATION/PERMIT PLUMBING-MECHANICAL 26768 C 7`+ p
BUILDING PROJH(:'1'IURN'pIFiCA'p1N:
0 . G C7 C7 O
BUILDI DRESS: - SANITARY NO. APPLICNION SUBMITTAL DATE.
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OWNERS ME: ^, P ONE: C R'S NA E: LICNO:
i NIC CONT'ROLN
as 9y
RCIII [CI' GINEFR: LIC NO: ADDRESS
e. . O W.
CONTACT: PHONE: fi"?`z'r5 bJU'n F R vrr�]-f*!-; f,:,N' BUILDING PERMIT INFO
QTY ELECTRICPHRM o (" ,I HIS )
BLDG P1.F.CT PLUMB
PERMIT
PLIA CES-RES
LICENSED CONTRACTOR'S pro DECLARATION pppLIANCF.S-RI?SIDENTIAL
lh7 affirm 3 ofth Business p ( eis in )OB D11CION
OCZ Y pmvisiavofChu ter9 commencin
�i100 Section]Bfq)of Division 3af the Business and Professions Code,and my license is in PANELS
pp4d W'FL".� full tome trod df
F<u License Cls 27 Lic.p Z 9� 40 UP T02fp AMPS
vs6y Dote Canmcta' /SI 201-["AMPS
ZO�r�' AR IIITECTS pECLARA'TION OVER 10D) MP
OZ—p I understand my plans shall be used a,,public records. SQ.Ff.FLOOR AREA $/g Q:FT.
F yuJ _ SIGNS ELECTRICAL
aN Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
iyax�OiU I hereby affirm that 1 an exempt from me Contractor's License Law for the
W 3Oti following reason(Sadao7031.5,Besi.,.and Proluriem Coda:Any city mw may TEMP.METER OR FOUR INST.
E-�rnn which requires apermit reconstruct,alter,improve,demolish,m,, mt
pair an structure
< I \ t' ll Vj,Vp
YWYn prior to its i,,w N
cc,n,o requires the appllcamt far such perair to ee signe4semem POWER DEVICES
yI a_ 0 that he is licensed pursuant to the previsions of the Continuum's License law(Chapter , I'^ F
'
°ags�e 9(comm
-,y encing with Section 7000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC d V W -
, or that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Scction7031.5 by tray applicant for a permit subjectsthe applicanOUTLETS-
no o civil penalty of SWH CHES-FIXTURES DAIP 29r
G
nELECTR
,more then five hundred dollars(5500). 5 .
❑ 1,asowneroftheprop ay,ormyemployeeswith wages eathefrsolecompemation, NEW RESIDENTIAL QIII, - STORES T ONSBUCTION
n willdo the work,and Omsvuetum is not mordedoroffered forsule(Sec.7044.Business
and Professions Code:The Contractors License law does nm apply to an owner of
property who builds or improve,,them .end who does such work himself or through his
mancroployces,provided rhatsuch impnecmcnmam not imeadedoroffered foriale.If, OCC.GROUP RES.UNITS
however,rhe bolldingor improvement is sold within one year tfrompletlon,themener-
huilda will have the burden of proving that he did not build or improve for propose of 'TOTAL:
❑ I,asownerofthe property,emexdus velycomructing with hansedcnmructomt LLLLFc} ; PLUMISING PERMIT. i 5� FE00D ZONE APN
consumer the pmjent(Sec.76N4,Business unit Professions CWc:)The Contractor's
Licenm LawdoesnorepplytoanownefofMm Mwhobuildsorimprovather ,and PERMIT ISSUANCE -
wbommractsfmsuchprojectswithaconwctoKs)licensed pumuem to the Contractor's
License Law. ALTER-DRAIN&VENT-WATER(HA) fi?;, _k3 p,FEE„$UMM_ARY,
❑ I am exempt under Sao. ,B&P C for this reason BACK FLOW PROTECT.DEVICE UU ISIM
SANITARY YN lir
Owns Dam DRAINS-FLOOR,ROOF,AREA.COND. RECEIPTN
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y_N
C3Ihemby affirm tbetlheveecrnificem of wnsenue self-insure,arettrtificete of FIXTURES-PER TRAP RECEIPT#
F Wmken'Cnmpensnriunlnsurarmeoracenificdcapy rhereef(See.Jg00,Leb C.)which PARK FEE Y_N
overs all employee's under this permit. GAS-E RECEIPT N
Policy N A.SVS'1'EM-I INCA OUTLETS BUIhpING DIVIpany SION FEES
0 Certified copy is hereby famished. GAS-EA.SYSTEM OVER 4(EA) PLANCHECK FEE
Cert
❑ Certified copy is filed with the city lnspectiandivision. GRPASIVINDUSTRL WASTE INTERCEPTOR GRADING FEE
CER'DrICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thissatlomnoed notbensmpletcd iflhepermil isforomhundreddollars($100) SEWER-SANITARY-STORM EA.200F1'. ENERGYMEless.)
I comfy that in the performance turns work for which this permit is issued,Ishall WATER HEATER W/VENT/ELECIR
not employ any person in any manner eo as 0 become subject to the Workers' PAID
z Compensation Laws of Califtmia. Date WATER SYSTEM"REATINO Date Receiptp
0 Q Applicant
NOTICE TO APPLICANT:If.After making this Certificate of Esemption,you should NEW RESIDENTIAL PLMIL SQ.ET. TOTAL:
V] become subject to the Worker's Compensation provisions of the labor Cade,you must
fonhwilh comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
pW, z CONSTRUCTION LENDING AGENCY SEISMIC PEE
I hereby affirm lhad'here iso connrucdon lending agemey for the performance of
mit
U the work for which this peris issuW(Sa.3097,Civ.C.) TOTAL: ELECBIC FEE
V. Lenders Name
Utenders Address QFTY ?�_', ,MECIIANICAL PERMIT> j$e'* s?PPE$*q, PLUMBING FEE
1 vanity that I have read this applicaunn wit erect that the above informations `#' .g 'b .4, +I e
�ba
0. correct.I agree to comply with all city and county ordinances and sine laws relating to PERMIT ISSUANCE MECHANICAL FEE
buildingcamoruclian,and hereby acth urim representwivea ofthis city mcmter upon the
V Z ahove-mentioned pmpcny for inspection purposes. ALTER OR ADD TO MECEL CONSTRUCTIONTAX
(We)agree m save,indemnify and kap harmless the City of Cupertino against
liabilitiesjudgmems.sce; sees whichmay ineny way accme agairrt said Ciry AIR HANDLING UNIT(TO 10,0011 CPM)
in co uenc,of ming of th permit.
_q AIR HANDLINGUNIT(OVER 10,000CFM)
arc of ApplicanUCmaracmr Dem EXHAUST HOOD OVMUCIT
PAID
HA9ARDOUSMATERIALS ptoCL howill HEATING UNIT(TO 100,0110 BTU) Uem RaciptN
Will the the Chinaman
aforumbuplCoccupantstoreor handle Health and
Safety
as defined by the Cupertino Municipal Cwk,Chapter 9.12,and the Health end Safety HEATING UNIT(OVER IW,IXIp BTU) TOTAL:
Coda Section 23532(u)7
1:1 Yes 0 N VENTILATION PAN(SINGLE RESID)
ISSUANCE DATE
OR 100,0110BTU
Will the applicamorfuwrc building occupant use equipmemmdevices which emir BOILER-COMP( )
ImsuNnus air ctnwmi owns as defined by the Bay Are.Air Quality Management BOILER-COMP(OVER IW,WO BIL)
Disvict7
L7❑Yes ❑No NEW RESIDENTIAL MECH.—SQ,FI'.
1 have read the hazardous materials requirements under Chapter 6.95 of rhe
California I Icahn&Safety Code.Sections 25505,25533 and 255]4.I understand that
rhe building does not currently have a tenant,that it is my responsibility m notify the
occupant of the requirements which must be met prior to issuance of a Certificate of
ocrapanq.
Owner m lowharzed.gen' Date TOTAL: ISSUED BY:
OFFICE