26239 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RDII:DINT.-F,I:, IGUAL PERMI'P NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION - - .IIUILDINO PRO.IF,(:'I''IDENI IIIICA'I'ION 26239
BUILDING ADDRESS: �L SANITARY NO. APPLICATION SUBMITTAL DATE
OWNS
NAME: PHONE: CONT CTq'SNAMH: LICNO:
ARCl
Q f//�,,Ir N/C CONTROL«
• I II IECT/ENGINEER: LIC NO: A URN. El
CONTACT: PHONE BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
eq-/- OnCS PERMIT ag BLDG ELECT PLUMB MECH
of �I�a s)�
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL F-1 El ElY6!
pzz I hereby affirm that l am licensed underprovislomofampar9(commencing with JOB DESCRIPTION
Fs00 Section 7")of Division 3 ofthe Business and Professions Code,and my license is in PANELS _
Fye folI force and It �i
FZW License CF' Lic.p �! 75` UP T02W AMPS _
ti=y Data Contrectn yt /n / 201-I0gOAMPS
ZOyZ ARCHITECCS DECLARATION OVER IWO AMPS %.�L AL9 E/SQ.FT.
CZ e [and I my platys shall be q d us public records.
SIGNS ELECTRICAL - �-�
6y , LicensedPro al
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. b
XOaF. 1 hatch affirm that I am exempt from the Contradofs License Lew for the
WapH followirlima,on.(Section'1031.S,Businessmd Professions Cade:Any city or county TEMP.METER OR POLE INST. TE V
m, which ml a permit be em stme6 alcor,improve.demolish,or repair any structure
C }2 prior toils vasomme,also requires theepplicam for such permiuo file.signed aetemem POWER DEVICES
4Kq<C, that he is license([pursuant to the Provisions ofthe Connector's license Law(Chapter SWIMMING POOL ELECTRIC
9(eommencing with Section](100)ofDlvisinn 3 countsBusinessand Professions Code) VALUATION -
y)�y or that he is exempt and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES / D ! ()�
F-ZQ Section 7031.5 by unyapplicam forapermitsubjeels theapplicimma civil penahicaf
not mare than five hundred dollars(E5W). '
0 C31,asownerofthepropeny,ormyemployeeswithwagesnstheirsolecompensation, NEW RESIDENTIAL ELECfRS Q.FII STOR-1 TYPECONSTRUCTION
a wbldothcwork,mdthesbumure isnm imended proffered for sale(Sec.]044,Business
and Professions Cede:The Comment's License Law does not apply to an owner of
property who builds orimproves thereon,and who does such work himself or through his
employs,provided that suchimpevemenrs arc nn[intended mattered for sale.IL OCC.GROUP RES.UNITS
hoee
wever,the huddingor improvement is sold within oneyearefcomplelme,thaewner- OCTAL
huilder will have the burden of proving thin he did nm build or improve for purpose of
sale.).
❑ I.asownerofthe Pmperty.amexclusivelycomeningwithlicensedcomecnem QTY' PLUMBING P17RMIT FEE FLOOUZONE APN
construct the project(Sec.7044,Business it Professions Cwe:)The Conrecmrs
License Law arcs not apply usanowner mproperty wholumids orimproves thereon.and PERMIT ISSUANCE
wh000ntracttsfnr suchpr°jeswithacontrano(s)Iicensedpumenmfin,Careacmis pRA1N&VFiYT-WATER(EA)
License law. ALTI?R- MSUMMARYUMMARY❑ 1amexemptunderSee ,B&PC for thia,ween BACK FLOW PROTECT.D13VICE ID: •EESOwner Dom Y NDRAINS-FLUOR,ROOF,AREA.COND. F.CEIPI'«WORKMAN COMPLNSATION DECLARATION N❑ Iherebyaffithu[I haveacenifeme of consem melf-insum°racenificale of ECI?IPI'«FIXTURES-PER TRAPWkcrs'Compenawi°nInsurance ma cCttified copereof(See 3gW,Leh CJwhich N3GAS-I?A.SYSTEM-I INC.40IJ'fLBTgEGI?IPI'«P°Icy« / DIVISION FI?ESCorn'sue to I—tf-gr� GAS-RA.SYSTEM OVER4(EA)
Certified copy is herehy furnished.
Certified copy is filed with Rte city inspection division. GREASIVINDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEIRAP SOILS FEE
COMPENSATION INSURANCE
(,his section need not he completed ifthe permit is forone hundred dollars PHW) SEWER-SANITARY-ST ORM HA.2001q. ENERGY ME
or less.)
I certify thin in the perfmmance.fthe work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so m to become subject to the WorkersPAID
z Compeneatkm Lmsof Culifomia. Date WATER SYSTF.MrHUATING Dom Receipt«
Applicant —
zO NOTICE TO APPLICANT:ILafter making this Certificate of Esemptioa,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
E-' V) become subject to the Worker's Compensation provisions of Ne Labor Code,you most
forthwith comply with such provisions or this permit shrill No domed revoked. BUILDING FEE qp�
.OV
0. (� CONSTRUCTION LENDING AGENCY SEISMIC PER a 7"Yl
:Dz Ihereby affirm that hare is a construction lending agency for the pmfrsomee of ` fes
U O the work for which this permit is issued(Sec.309],Civ.C.) TOTAL: ELECTRIC FEE
p Lender's Name
Q U Lender's Address QTY. MECI IANICAL PERMIT FEE PLUMBING FEE
1 certify that I have read this application and sum ohm the above information is
correct. l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL HE
t,,' building construction,and hereby omhmiecrepresenntivesoflhis city to enter.,in the
L) IZ above-mentioned property for inspection purposes. ALLMORADD'1'OMECIL CONSTRUCTION TAX
(We)agree to save,indemnify and keep hvmless the City of Cupertino against
lishilitiecitulgmcros,costsandexpenses which may in any wayaccboagainst said City AIR HANDLING UNIT(TO H0,090 CFM)
no Coca uenreu the'raningr thio pcmtit.
Q — t• p AIR HANDLING I1NIT(OVI?R IO,OW CI+M)
il
Sign aw of Applicant/Cotvecmr tJ Da¢/ EXHAUST GOOD(W/DUCY)
PAID
HAZARDOUS MA,'ERIALS UISCLOSURI? HEATING UNIT(TO IW,IXJ(IBIG) Date RecciptN
Will the applicant m furore building occupant some or handle hazardous material HFA,'ING UNIT(OVER 100,001)BTU) TOTAL r,
m defined by the Cupcnino Municipal Code,Chapter 9.12,and the Health and Safety
Cale,Section 25532(a)'J -
❑Yoa LQ'No VENTILATION PAN(SINGLE RESID)
BOILER-COMP(311P OR 1 Wd100 BTU ISSUANCE DATE
Will the.11 cartoon
a.building by the
nBay equip mem orality Manalumch eat )
. hazmdous air cnmaminants es defined by the Bey Area Air Quality Manegemcm BOILER 100,0110 BTU) p
rnatdm+ iY
❑'es
ANo NEW RESIDENTIAL MECH. SQ.FT.
1 have read the hazaMous materials requirements under Chapter 6.95 of the APR _ 5 1994
California I Health&Safety Code.Sections 25505,25533 and 25534.1 undeennd that
il'the building does not curtcntly have u tenant,that it is my responsibility in notify the
ccup be ecyune to s which must be met prior to issuance of a Certificate of
Occup cy.
�s y CII I UrurrhllN1U
Owaerm rnimdagem Date TOTAL: ISSIIEp BY: rtd. (JC
OFFICE