26187 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINORIAY]ST.'RI.F.rM17x. PERM IF No.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJET IEF..Ff(FICA r1ON
BUILDING ADDRESS:
SANI'T'ARY NO. APPLICATIONSUBMITTALDATP
A Il UNITO`1'N
OWNERS'NAME: PHONE: TRACTT OR'$NAME: LIC NO:
VJV
y 9& O / 90 NIC CONTROhp
hr AR [ITEC'TIENGINEIR, LIC NP DDRESS 1i
CONTACT: PITON
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
- D S' FLECf PLU M C
PERMIT ISSUANCE
1.1 SED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENT]
0Wz Ihereby affmuhut I all,licensed underprovisions ofChnpla9(commenting with 49 LOB D„C ION
{n 00 $emion]IXIB)of DivisionJof the Business and Professions Cade,and myliceveis in PANELS
tyU1- full force anJc I.
yzw Dole se hiss- 'Lic.N X90 UP TO Sw
1v�`
=y _ Crntnnor 1 .rysd 30 1 PS
zON? ARCHITECTS GECU RATIO O AMPS SQ.F7.FLOOR AREA Ff.
O z—Q I undeannd rat plans shall be used as public records.
F N L....II SIGNS FL?CI'RI
6 Licensed professional
OWNER-BUILDER DECLARATIONSPECT CR U Sc.
°xx'OaF 1 hi affirm that I ren exempt from the Contractors Licenu Low to he
W30.w following rcason.(Smtion 9011.5,Business and Professions Code:Any city arc a, TEM hiI ;R OR PO INST.
4��g which requires a permit 0construct,almT.improve.demolish.or repair mystmnum
aM priartn its issuanre,alsa requires theappli.ma farm,Permit to fileasigned smmment PO DCVI
pj a 00 that he is licensed pursuant o the provisions ofthe Contractor's License Law(Chapter
ad m
9@nmencing with on]0
Secti )0)ol'Uivision 3ofthe Business and Pmfessionx Code) SWI MIN OOL ELECTRIC . ta
W—, omhat he is exempt and the basis for allegedexemption.Any violation of is, V AVAWUA ATI(uCJJLL++—
Section 7031.5 by any applicant for a lnn nnit subjects the applicant In civil penalty of OUTLETS-SWITCHES-FIXTURHS
ran more than five hundred dollars($500).
� � ❑ I,uownerof@cpropeny.mmyemployees with wagesastheirsolecompensition, NGW RFSIOFMIAL ELECIR __SQ.FT. STORIES TYpIi CONS'I'RUCI'ION
W will do Ihowork,snaffle simulate is not imnulcdaroUued for irate Fier.7044,Business
and Professions Code The Contractors License Use does not apply to an owner of
property who builds or improves Nereon,and who does such work himselfor through his
own cfnployces,provided that such improvemcrosare not intendedmolomest forome.If, - OCC.GROUP RES.UNITS
ld
however,the buildingor improvement ixwld within oneyearofcomplelion,theawner-
buierwill have the burden of proving that he did not build or improve for purpose of L
olto
❑ I.mownerofthe Propeny,amexelusivelycm"cling with licamedconaacmrsm QTY' PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7844,Business and Prnfeasin v Cade)The Carl mcad's
License Law does not apply n an ownerofpropeny whubuildsorimproves Nereon,and PERMIT ISSUANCE
who contracts for such Projects with a commandos)licensed pursuant to the Commetor s
License Law. ALTER DR F. :R )
❑ 1 am exempt under See reactionFEE SUMMARY
,B&P C for this reaction E OG d:
BACK ROW ROI i ACL
Owner Date SAN ITARY YN_-
WORKMANCOMPENSATIONDECLARATION DRAINS-FL RI O�IA 1 �C I RECFIPTN
❑ 1hembyaffinm that l have acenificae ofconseen toself-insum,oracenlficate of SCHOOLTAX Y N
WorkeriCompensation Insurance or a ccmfrcd copy thereof(Sm.3800,Lab C.)which FIXTU IES-PER TRAP / O RECEIPI'N
en ell ploy«s under t 'a ( PA K FEE "y
Palic,# m0W N1N�t59a) GAS- � .SYSTE -I NC.4 ECF.IPI'
Company LIn lia r -' BUI . TVI NFEE
❑ Cenifiedcopyishercby(umished. GAS-EA.SYSTENFOVER 4(EA) PLANCHEC
B"Cenithdcopyis filedwith Racily inspledmodivision. GREASFAINDUSTRLWASIR INTERCEPTOR GRADIN
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP 501
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is foromehundr>d dollars F$100) SEWER-SANITARY-STORM FA.3WFT. EN.RGY 'Ls O
or less.)
I certify that in the performance of the work for which this permit is issued,l shall WATER HHAI'ER W/VENOELECI'R
not employ any person in any mummer so ss to become subject to the Workers' PAID
Z CrmPcnsation Laws of Celifomia. Dam nt WATER PAID me Receiptq
Q O NOTIAppliCE
Z NOTICE TOAPPLICANT:IL romer Contminiti this Cisions roof Exemption.you you must NEW RESIDENTIAL PLMB. SQ.FT.
F > becomesubjectcomply
the Workers Compensation pfovisiorel ba,
Labor re maid. must _ TOTAL:
� , fonbwith comply wi0r such provisions co permit shell be deemed mvokal. �^ BUILDING PEE
hG1 Q Ct NSI them iUC.ONLENDING AGENCY SEISMIC IgiE
z Therebyhich this permit
is ecnnaduction 11 Civagency for Ne performance of
the V O Leaders for which this permit is issued(Sec.301 Civ.CJ L: ELECTRIC IRiE r
Lir r.f
Leaders Namc -
U
Linda's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEB
I certify thaw 1 have read this application and store that the above information is
Na cormct. I agreo in comply with all city and county onlinanees and cram lows relming to PERMI'I'ISSUANCI? MECIIANICAI.PEE
(^ building construction,and hereby aathom
dm pramoatives of this city m enter upon the
V FFFj777 above-meminned pmpeny for inspection putpous. ALTERORADDTOMBCH. CONSTRUCTION TAX
We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgmems,costs and expenses which may in any way raceme against aid City AIR HANDLING UNIT(TO 10,"CFNE
//in
on quence of a greening of a Penni
3a3-9/ AIR HANDLING UNIT(OVER IR000 CPM)
3grearm.f Allpbcam/Cmumemr Dan HXHAUSTHOOD(W/DUCt
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dem Ree IN
Will the applicant or fume Municipal
C occupant erre or handle hazardous a d Safes
Care,Socum the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IW,IXq III U)
Cade,Section 35533(e)?
❑Yes C1 No VFNI'RATION FAN(SINGLE RESID) -
Willtherpplicam orlhwmbuildingmeupantumequipmentordevices which emit BOILER-COMPUFFOR I W,o00 BIT) ANCED E
hazardous air cnntomirmin us defined by me Bay Arca Air Quality Management BOILER 100,000 BTU) R M3
Distnn? m
❑Yes 0N NEW RESIDENTIAL MBCA. SQ.IT, lilt! I'
I have read Ne hazanlous armerirls requirements under Chapter 6.95 of the q� Y vh 1$94
C alifrmie health&Safety Calc,Sections 255()5,255U wd 25534, lemundmnd that I/ LVJ-'e/y//ryU
the building arcs not cunemly have norm,then it is my respanxibility a nosily the
9�99pt of the quirement h muu be met prior to issuance of a Certificate of
It
is mer ar rat � 3
for edagent r Dam'— I ISSUED BY:
OFF]