26873 CITY OF CUPERTINO
INSPECTION DIVISION
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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT-PEN ONLY
CITY OF CUPERTINO HD'DfNG-EI'RCTRic -TRRMD'NO,
APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING DIVISION BUILDING IBOJkCI'IDNN'I'IItlCA'1'ION 26873
BUILDING ADDRESS:2 SANITARY NO. A/P(YL\ICA'�1ION SUrB'MfI'1'AL UATI
ZZO2..,3 UAX L6 y 1 UNIT# LOTH
NERS NAME: �PHONE: C TRACTOR'S NAME: LIC NO:
SRCuq� MvreTYy L-S3 3 �w`N4L El corv'rkol.«
RCIIITECf/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTORnderpmSDECLARATION APPLIANCES-RESIDENTIAL �V�I
pyo Ihcreby affirm Nm l 3 ofthnsedunderpmvisioosof Cheplerand mmecesse with
<X00 full force an cfDivision3of the Business end Professions Code,v�d my licemeis in ppNFJ,S
full farce and effect.
I,cA< LLiic1ense Class Lit.#actin UP T0200 AMPS
F'yZ ARCHITECTS DECLARATION 201 IIppAMPS SQ.FT.FLOOR AREA S/SQ.FT.
ZOZ y G 1 understood my plans shall be useas d public records. OVER 1000 AMPS
O
F-=F� SIGNS ELECTRICAL
<Y2, Licensed Profusbmal
C
cc< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XO i F 1 hereby affirm that 1 am exempt Gam the Convector's License taw for the
F¢
tO m following reason.(Section 9031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
,n which requires a permit to construct,alter,improve,demolish,or repair any structure
WW>2 priorto its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
E,W<OO that he is licensed pursuantto the provisions of the Contractor's License law(Chapter
d X�LL 9(commencing with Section 9o00)of DivisimnJof the Business Nod Profusions Code) SWIMMING POOL ELECTRIC VALUATION
ta_w or dera he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES
F Z Q Section 9031.5 by any applicant for a permit subjects the applicant to a civil penalty of FIXTURES
not more than five hundred dollars($SM).
NEW RESIDENTIAL ELECTR —SQ.FT.
y3=°zFo ownerand bestpery.ormyempindedorohwegesutM1ei(Sce. 0m,Broatirn, STORIES TYPE CONSTRUCTION
will mhework.CWe structure is not irn License
ave do forotapplyAl144,Busine ss
and fexsions Cade:The Contractors License Lew does not apply w an owner of
properywhobuildsorlmproveatherc n,and wbodocssuch workhimulforlhmugh M1ia
employees,provided that such impmvementsa ,not inumailorofferdfors 11s. OCC.GROUP RFS.UNITS
however.the building or improvement is sold within one year ofcompletion,the owner- TOTAL:
builder will have the burden of proving thn he did trot build or improve for purpme of
sok.).
❑ 1.se.wnerofthe property,amexclusively contracting with licensed convectors to QTY' PLUMBING PERMIT FEE -----Fl O ZONE APN
construct the project(Sec.7004.Business and Professions Code:)The Comuacmn
License Lawdoesnm apply roan owncroPoi whobuilds or impmvuthcreon,and PERMIT ISSUANCE
who contracts for such projects wi th a comraaom(s)licensed pursuant to da Conbamofs
License law. ALTER-DRAIN&VENT.WATER(G) FEE SUMMARY
❑ 1 am exempt under Sce. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OfITSIDE FEF_S
SANITARY Y_N
Overset Dam DRAINS-FLOOR,ROOF,AREA,GOND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ (hereby affirm tMtlhaveeccnificme of coruemmxlf-insum,orecenificme of FIXTURES-PER TRAP RECEIPT#
1W 'verso Cumprnsationithincemrecenified copy thereat(Sec.38g1,labCJwhich PARK PH Y_N
vers all employeaS uMer this permit. BUILDING DIVISION F
� GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEII'I'N
Co. N FE-ES
Company GAS-EA.SYSTEM.OVER4(EA)❑ Crnifiedcopy is hcmby famished. ( PLANCHF.CK FEE
❑ Ccrified<opY is fled wird the city inspection division. GREASE SIDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GR[iASETRAP SOILS FEE
COMPENSATION INSURANCE
This section rxeE not be completed time Permit is for one hundred dollars($100) SEWER-SANITARY-STORM F.A.200FT. ENERGY FEE
orlcss.)
I certify that in the pexforrrtons,of Ne work for which this permit is issued,I shall WATER HFATFR W/VRNT/ELEM
not employ any person in any manner so as to become subject to the Workers PAID
z Compenmtion Uwsof Califomia. Dam WATER SYSTEMAREATING Date Reaiptp
Applica t
z C) NOTICE TO APPLICANT:If.after making this Ceniflate of Exemption,you should NEW RESIDENTIAL PLM B. SQ,ET. TOTAL:
F-' r become subject 10 the Workcls Compenxtion provisions of the Labor Cade,you must
forthwith comply with such Provisions or this Permit shall hee mnt revoked.d
(� 7 BUILDING FF.F.
IL
Q. Q CONSTRUCTION LENDING AGENCY :CONS�UCI
—D z 1 hereby affirm thin them is a construction lending agency for the performance of
U C) the work for which this p<.it is ixwa J(Sec.3097,Civ.C.) TOTAL: .E
Lenders Name
pU Under',Address QTY. MECHANICAL PERMIT FEE FEE
[Ta I cenify that I have read this application and sate thin the above boundaries is
F" 0. coned.lags to comply with all city and county ordinances and nam laws relating to PERMIT ISSUANCE LFER
building connrucnon,and with all city and
rcprey ordinances
Nis city roamer upon to
V z "rove-incmioned property forimpeaion purposes. ALTER OR ADD TO MECII. ION TAX
(We)agree m save,indemnify d keep harmless Nc City of Cupertino again"
liabilities,'udg u,crosa under.which may in any weyacer gain said City AIR HANDLING UNIT(11110,!1010 CFM)
co u grand gofN n.
ec . e o 'I AIR HANDLING UNIT(OVFR 10,00OCFM)
ignamrc of Applicantt/Con m 'Y Dme I EXHAUSTHOOD(W/DUCn
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT GM 100,0010 BTU) Dole Receipt#
Will Ne applicant or future building occupant since or handle humorous material
a1 defined by the Cupertino Municipal Code,Chapter 9.12,and the Health toad Safety HEATING UNIT(OVER zooloa)ETU) )
Code,Section 25532(np
11 Yes E)No M101AL:
(SINGLE RESID)
Will theapplicanmrfulurebuildingtxcupamuse Wuipmemmdeviceswhich emit {p OR IIXI,OIXIBTU) ISSUANCE,DATE
�•hazardous air common..as defined by the Be,Area Air Quality ManagememVER 100.000 BTU)
m � A D
/ ❑Yes ❑No RESIDENT IAL MECII. SQ.PT.
I have read the hixardous mmcrials rev, itcoems under Chapter 6.95 of thee��
— � California llealth&Safely Code,Sections 25505,25533 and 25534. I mdummad Nut /All ����
building the res not nients currently have h moa tenant,thin it is my responsibility,jocof
m notify hev
f the rcquircmm�a wM1ich mutt M met prior to issuance of u Cenifcate ofaulhmn.. agent
-Dole 'f
'1'Ol'Ah: ISSUED BY: