26825 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
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CITU'OF CUPEPLUMIi1NG-MECHANICAIPERMIT NO.
BUILDING DIVISION
loN APPLICATION/PERMIT
' BUILDING PRIIdNC'1IDI:N'1'IN'ICATI(lN 26825
BUILDING ADDRESS: �/�} SANITARY NO. APPLICATION SUBMI'PI'AL DATE.
2 / rl �� UNIT# LOTH p(?o3 9q
OWNER NAME:or
PHONE: CONTµ CI'OR'S NAME: LIC NO.
�( 25 P L r L N/C CONTROL#
OARCHITECT/ENGINEEK: LI NO: ADDRESS: CJ J -IJ ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
22Q ! ; ELECT
906 Z PERMITISSUANCE al PLUMB MECH
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIALis xe_, N ❑
as alaq
❑CZ Ihereby of not that l am licemedumder provisios
nof Chapter 9(commencing with 1g
FJOC[:.) Section]000)of Division 3ofthe Bminess and Profession Cade,end mylicense is in PANELS ^'�sr
ce V k0 full force and effect. n
License Class Lic.N UPT020( AMPS KLJrn��
rFit Qty Dau Contrmur 201-1000 AMPS
F res Z_ ARCHITECTS DECLARATION SQ.FT.FLUOR AREA S/gQ.FT.
Zorn 1understandm 1 p OVER 1000 AMPS
pZ—p yp ons shall be usedm ubli<recoNs.
1—t�F W SIGNS ELECTRICAL
Q—ee� Lmensed Rafessronel
r gR!u OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
X060 1 hereby affirm that I sat exempt from the Contractees License law for the
W 3 a ti following reason(Section 703 L5.Business and Rofeasi...Code:Any city inventory TEMP.METER OR POLE INST.
which mquiru a permit to construct,alter,improve,demolish,or repair any structure
2�T priur to its issuance,edea requires the applicant for such permit to file a signed statement POWER DEVICES
.,Y<O that he is licensed......to the porilkioai of the ContractorsLcenu law(Chepwr
d XeW, 9(commenting wllh Section 7000)of Division 3ofthe Business and Professions Cade) SWIMMING POOL ELECIRIC VALUATION
W_rn arthro 7031. by alherefmmmfor the a bastheidItIped theaq, prion.Any violation of �
�ZQ Sechot carn7WL5 v anndredappliesint do[[. S50(j subjects the epplicanuoarivil penalty of OIITIEfS-SWITCHES-FIXTURES ��
not more then five hundred dollars(5500).
W m ❑ I,azowncroHhepropmy,armyemployeeawithwagesut irsolecomp radon. NEW RESIDENTIALELECIR _SQ.FT. STORIES TYPE CONSTRUCTION
a3— willdmthe week,sod Ne omcmreis not imendedoro(faced fmrele(Ses.7014.Business
and Professions Code The Commerce.License Lew does not apply to an owner of
property whobuildsorimpmvestionom,a ilwhodousuchwork himulforthmughhis
ownemployces.provided that such her ovememeamnot intendedoronercd forule.if, OCC.GROUP RES.UNITS
however,the buildingorimprovement is mid within one yesrofmmpletion,theowner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,Uownerofthepmpeny.amexclusivelycantneiingwiNlicemulcon=tonto QTY. PLUMBING PI7RMIT FEE FLOOD ZONE APN
construct the project(Sec.7044,Business and Professions Code:)The Contemn"
License Law does not apply to an owner of property who evil Ids or improvesthemon,end PERMITISSUANCE
who commas for such projects with a conuscmKs)licensed pursumuo the Conuactoea
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt-der Scc ,B&P C for this moron gACK FLOW PROTECT.DEVICE OUTBID E
SANITARY Y N
Owner Dem RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOP,ARF.A,COND. SCHOOLTAX YN
• Wi co'Coyaffirmtbatlhrance Oificmaof comsemuomf(Scsum,or UbC.) hick MIXTURES-PER TRAP RECEIPT'#
Wmrkers'Cmmpenm[iminsurance oracMificd copy themof(Sec.3800,LebCJ which PARK FEE Y_N
M all employee's under this permit.
Policy# OAS-T:A.SYSTEM. INC.4 OUTLETS REIVISM p
BUILDWGD 51 FE
Company GAS-FA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is heathy famished, i
❑ Certified copy is fled with the city inspection division. GREASE/INDUSIRL WASTE INTERCEPTOR. GRADING FEE
r
CERTIFICATE OF EXEMPTION FROM WORKERS' µ q ; µ p SOILS FEE
COMPENSATION INSURANCE is
(This aeaimn need not be completed if Ne permit is for one hundred dollars(SIM) 1 SEWFtR/,, IT�AItIY- 30RM EARO�IPTIf ENERGY FEE
o Iess.7
(certify Nnt in Ne perfonnmce ofthe work far which this permit is issued,Ixhill •% -WATP.R H!kTER .1.
not employ any person in my manner so es to become subject to the Workers' PAID
Oz Compensation Lawsof Cabouriia. Date ATER 5 Date Rxeiptp
O Applicant IF
NOTICE TO APPLICANT If,after making this Cenifcme of Exemption,you mould NEW RPSI DENTIAL MOB. SQ.PT. TOTAL:
V) become subject o the Workees Compuention provisions of the Labor Code,you mail
a H forthwith comply with such provision or this permit shall be deemed revoked. BUILDING FEE
LFaA CONSTRUCTION LENDING AGENCY SEISMIC E
z I hereby affirm that there is 4 construction lending agency for the perfenmance of
C.) O the work for which this permit is issued(Sec.3097,Civ.C.) ELECTRI
Trades Name
Q U Lendees Address QTY. MECIIANICALPHRMM FEE PLUMBII certify that 1 have read this application and state that the above information isMECHANcorrect I agate mcomply withall citysoolemmtyordinancesmd state laws relmingm PERMITISSUANCEbuildiagconstuctimn.and hembyeuNodae rapreaema[ivesoftbis city to cnfJ z above-mentioned properly for inspersion puryoua. ALTHRORADDTOMECH, CONSTRAX
(We)agree m mve,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in my way acerae against said City AIR HANDLING UNIT(TO W."CFM)
in mm equence of the grating of this permit.
/,y#''! w 5�, � AIR HANDLING UNIT(OVER 10,1100 CFM)
Signature of ApplicmUConuaclor Dme !Y— EXHAUST HOOD(WIDUC) /a
PAID al/`wJ
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IN,"BTU) Date Recei
Will the applicant or future building occupmutore or handle haaodous material `
or defined by the Cupenino Mmicipal Code,Chapter 9.12,and the Heahh and Safety HEATING UNIT(OVER 100,0001ITU)
Cade,Scedon 25532(a)?
❑Yes 0N VENTILATION FAN(SINGLE RPSID)
Will
• he aPlicamorfoure mildngoccu panise uipm Q athiit
BOILER-COMP(3HP OR IN."BTU) ISSUANCE
DATE
horrendousair contaminants n defined by the Bay Area Air Quality Management
Disuru,l? BOILER-COMP(OVER IN."BTU) PAID
Cl Yes ❑No NEW RESIDENTIAL MECH. SQ.FT, UG 19
{� .3 /J
1 have read the hauolous minerals requirements under Chapter 6.95 of the fD Q�
if
uil Health&Safely Code,Seniors25EOA25533 and 25534. 1undenund for
V
if cu building does not mentacurrently have a must
be that it is my responsibilityuancoaa ramify the oil? (/r
axupmt of the requirements which must be ten prior m issuance of e Certificate of VVr
Occupancy.
Owner or amM1mxed agent pate T ISSUED BY: \VVJ1�7V,a��•}[I,