26048APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
(,TTY OF CUPERTINO HI II,DI .-ELF. '1'RICAL
APPLICATION/PERMIT PLUMIJING-MECHANICAL
BUILDING DIVISION BUILDING PROJECTIDRNTIFIL'ATITJN
PF.RMITNO.
26048
BUILDING ADDRESS -
SANITARY NO.
APPLICATION SUBMITPALDATE
C � UNIT# LOT#
�9��
O R NAME: PHONE:
�" s -
OR'S NAME: LIC NO:
a s s
N/C
❑
CONTROL#
f;RCHI ECIA INFER: LIC NO:
II
:
CONTACT: PHO NH.
ELECTRIC PERMIT PEE
BUILDING PERMIT INFO
BLDG ELECT PLU H TOP
RMIT' ISSUANCE
1201
❑ � 1 ❑
LICENSCDCONTRACTOR'SDECIARATION
I hereby affirm thin I um licensed mderpmvixim,of Chapter9 (commencing with
PLIANCES - RESIDENTIAL
JOB DESCRIPTION
Section 0111X11 of Division 3 of the Business and Professions Code, and my license is inNELS
full force undo�F— pd
License Classes Lir.# a,?s-
T02W AMT'S
Uuta A Contreaar 'ti•
� J_ / zARCHRE S'DECLARATION
understood my plans shall be used in public records.
r
- I"AMT'S
SQ. FT. FLOOR AREA
E/SQ.II'.
OVER IOW AMPS
SIGNS ELECTRICAL
Licensed Pm(asianal
OWNER -BUILDER DECLARATION
SPECIAL CIRCUPOMISC.
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason.(Section 9031.5, Business and Professions Code: Any citymcounty
TEMP. METER OR POLE INST.
which orthams a permit to construct, alter, improve, demolish, or retain my structure
prions its issnunce, also requires the applicant for such permit o rile a signed statement
POWER DEVICES
,hot he is heense:I ,ammoun m the provisions of the Cantnstor's License Law (Chapter
a(commencing with Section 70010) of Division 3 ofthe Ba,mc,sand Professions Code)
or but he isexcmpt thcrefrnm and the basis for lheallelyd exemption. Any violation of
Section 7131.5 hymy applicant for a permit subjects the applicant to a civil penalty of
SWIM MI NG POOL r.E C
—
OUTLETS -SWITCHES TXT RAS\. -', �.. �.
ISOd
VALUATION
�0
(F'�/
not more Ibmm five hundred dollars ($500),
❑ I,nvmwnerrftheproperty,ormy employees with woges usthcirealecompensetion,
a
NEW RESIDI;N'19AL EL �R/ \ I�Sm
61 q
S RIES
I YPH CONST RUCTION
wil l do the work, and the wroulme is not intended., offered for s ile ( See. 744, Business
,
and Professions Coda The Contractor's License Law does not apply to an owner of
,.,my whabuildsor improveldereon,and whodoes such workhimaelfonbrough his
ownempinyee5,pmvidMthatsuchimpmvemenms nmintendMoroffemdforsale. If,
OCC ROUP
_
RIS. ON
TOTAL:
however, the buildingor improvement is sold withinom yearo(completion, theowner-
builder will have the burden of proving that he did not build or improve for purpose of
QTY. PLUMBING PERMIT FJiE
sale.).
❑ L m awocrofthe propcny, amexclusivelycomructing with he .... dmntrecmrsm
FLOOD ZONE
APN
construct the project (Sm. 7094, Business end Professinna CNet) The Contractors
License Lawdoes not apply m mownerofprolamy who builds or improves thereon.and
PERMIT ISSUANCE
L i0c,
License ow.els fursuchprojedswith acontrecmr(s)IlcemeJ pursuant Contractors
License Law.
nl
ALTER - DRAIN & VENT - WATER (HA)
FEE SUMMARY
❑ cin exempt under Sec. , H & P C for this reason
BACK FLOW IRO'1'IEC'f. DEVICE
ODI'. IDh FEES
SANI'T'ARY YN
RECEIPT p
Dnte
WORKMAN COMPENSATION DECLARATION
IT, ROOF, AREA. .
DRAINS - FLOOR, GOND
SCHOOL . Y N
'Owner
I hereby affirm mlummhave ecm.cemof copfitof(ire. 3100, Lm C.) which
inmrance oracmified copy themnf(Su. JS W. Lab CJ which
nrustil
RECIEII'fp
FIXTURES -PI?R'1'RAP
PARK PEE Y N
eampensmion
ry elle y�eq pJer this permit.
1'olicyN �J//n —
RIECIEIPT p
GAS-EA.SYSIEM-I INC.40UTLGfS
BUILDING DIVISION PEPS
Company R �
GAS - EA. SYSTEM -OVER 4 RA)
PLANCHECK FEE
❑Cenifim copy is hereby Fortified.
OREASUINDUSTRL WASTE INTERCEPTOR
GRADING FEE
r\ CboifiM copy is filed wimflaw city inspection division.
CF.RTIITCATE OP EXEMPTION FROM WORKERS'
GREASE'IRAP
SOILS REE
COMPENSATION INSURANCE
SEWER -SANITARY -STORM F.A. 2001`117.
ENERGY FEE
(This section need nm be completed if Ne pemlit ix forone hundrW dollars ($IW)
or less)
lrectify that ethe ework far issued,rkers
WATER MEATIER W/VEM'/ELECTR #
labormhispcmnito
not employ any person In my manner so as w become subject to the Workers'
son inomym annex
PAID
Cmnpcnmtion Laws of California. Date
WATER SYSTEM(1'BEATING
Doc Receiptp
APPIIctnn
NOTICIVI'0 APPLICANI':If, after making this Cenilicam of Exemption, you should
NEW RIESIDIEN'I'IAL PLMB. SQ. FT.
TOrAI;
become mhjed to the Workers Compensation provisions of the Labor Code, you Most
fonhw ult comply with such provisions or this permit shall be deemed revoked.
BUILDING FEE
SCISMIC FCC
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a construction lending agency for the performance of
the work far which this permit is issaail (S". 3097, Civ. C.)
TOTAL: ,S
ELECTRIC FEE
Lender's Name
QTY. MSCI IANICAL PERMIT FEE
PLUMBING FEE
Lenders Address
1 emify that 1 have read this application and state that the above information n is
correct I ugrm to comply with all city and county ordinances and state laws relating to
PERMIT ISSUANCE,
MECHANICAL FEE
building construction. and hereby authorize representatives of this city to mter upon The
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECH. '
CONSTRUCTION TAX
(Wa) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities,judgments, costs and expenses which may in any way accrue against said City
AIR I IANDLI NO UNIT (TO 10,000 CFM)
11 luencv of tha Printy (this per mit.
AIR IIAN DLI NG UNI'( (OVER 10,000 CFM)
noun of Ap(Otmnt Cmlbw or ,•S Data
HXHAUSTHOOU(W/DUCT)
PAID
HEA'T'ING UNIT TO 100.000 DIU)
Date Receipt#
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle lmazsrdous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
ELATING UNI'1'EOVER 100,000 OI'll)
TOTAL:
(
d .•.10
VENITILATION VAN (SINGLE RESTD)
Code. Sution 25532(a)^
. ❑ Yes ❑ No
A TE
Will Neepplicvttorfumre buildingaccupantuuequipmemordeviceswNchemit
�Dterardtous air contaminants ss defined by the Bay Area Air Quality Management
BOILER - COMP(IIiP OR I00,000 BTU)
1QQ
FEB —
BOILER-COMP(OVER 100,000 BTU)
❑ Year ❑ No
NEW RESIDENTIAL MECH.—SQ. FT.
1994
1 have mat the hmardous materials requirements under Chapter 6.95 of the
CITY OF LUNtH I IIVU
CaliforniaIlcalth & Safety Code, Sections 2"05,25533 and 25534. 1 understand that
If the building docs not rmovally have a tenant. that it is my responsihility to notify the
catmunt of the regairenmtns which must he met prior to issuance at a Cerificate of
Occupancy. -
ISSUED BY:
Owner aro undoubted! agent Date
TOTAL:
OFFICE