26417 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
URN(:-KI.F.CTR PERMIT NO. 26417/� A
CITY OF CUPF,RTINO APPLICATION/PERMIT PLUMBING-MECHANICAL. '/6 /I 1 7
BUILDING DIVISION BUII.DLNG PROdEtn'IIIENI'INICAI'I()N 2 6 4 1 1
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
DsftS mac{
LOTH
OW 'RS NAM S4�5J e6NMAcT R'S NAME: ,n G S LIC NO:
K/ NC CONTROL#
RCH CT/ENGINEER: a, LIC NOL AFD. SS:
.s BLL NOSTEIr.�I
ONI'ACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MUCH
PERMITISSUANCE �� ❑ El CONTRACTORS APPLIANCES-RESIDENTIAL JOBD DESCRIPTION
s�yIM1ereby affirm mmlamlicensd under provision Of Chepttt9(cormnencing with
0z,0Section]OW)ofDivisionlof the Buainep and Prorpsioru Code,and mylicense is in PANELS
566
Y full force and effat. + 1 r�
HZ Liceme Cl —_Lic.p ." 1 { d A 7f UPT020JAMPS I/'r�`` �-� •-as/'aC�,
FNF.�.6 y Dun;3�¢�_COnlractor 201-1000 AMPS -
ZOVysZ ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR ARBA $/SQ.FT.
O Z I understand my plans shall be used as public records.
rn SIGNS ELECTRICAL
4y LicemM Pmfeuional
"syr U OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISQ
KO U I hereby affirm that 1 am exempt from the Convector's License Law for @e
YT 3 y following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.MUTER OR POLE INST.
J y which regairsa a permit to comm ca,alar,improve,demolish,or repair any structure,
}� prior to its issuance,also requires the applicant forsuch Permit o file asignet statement POWER DEVICES
ul 00 that he is licensed pursuant to the Provisions of the Commences License Law(Chapter
y9(commencing with Sor on7")of Division 3 ofine Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
y or that he is exempt therefrom and the basis for the alleged exemption.Anyviobomm ofOUTLETS-SWITCHES-FI%TIIRES O
EZQ Section 7031.5 byanyapplicant faro pmtilaubjab lheapplicaat m a civil penalty of
Hnal marc than Eve hundred dollars($510).
e, ❑ I.Uownerofthe NEW RESIDENTIAL ELECIR —SQ.FT. STORIES TYPECONSTRUMION
pmprry,ormyempended oroferegespthei(Sm.co ,Business
yg_ and Professions
rdo thewons Cade: he Contractors
License
fwdoesfered of apply
Business
and sitywh obu Code:The Contracmr a nd who Lew des not apply to an owner of
pmpenywysix,pJvidedthat mvesch improvndwbotlresmcendidh work emselfor throughhie OCC.—GROUP RES.UNITS
wnemp.thees,p angor improvement
improvementhin notyearoedmoffered forsownle.Ir,
however,the have
the
bur improvement ix sold a did one year or improve for tbe0wner- —�
builds will love Ne burden of proving that he did not build or improve for puryox of
ale.).
❑ I,asowneroflhe property,atnexclosively convactingwithlicensetl cnntncmn to QTY, PLUMBING PERMIT FEE O.00D ZONE pPN
construct the project(Sec.7044,Business and Professions Code:)The Contractor's PERMIT ISSUANCE
License Lawdoes not apply an an ownerofpropeny whobuilds or improves thereon,and
who contracts for such projects with a commissariat licensed pmaamn to DK Contactors ALTER-DRAIN&VENT-WATER(PA) FEE SUMMARY
License law.
❑ I am exempt under Sec. ,B @ P C for Chia reason BACK FLOW PROTECT.DEVICE SANITARY Y D_N
Owner Data DRAINS-FLOOR,ROOF,AREA,COND. RECEIPTN
WORKMAN COMPENSATION DECLARATION SCHOOLTAX V N
'❑ I hereby aRum that l have a ceniftcme ofcmuenl n se161nsum.or a certificate of RECEIPTM
\Vmked Cmapensatinn Insurance or ecerlified copy thereof(Ses.3800,Lab C.)which FIXTURES-PER TRAP PARK FEE Y N
covers all employee's under Ms permit, GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT Is
Policy M BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) NCHECK FEE
❑ Certified ropy is hereby famished.
❑ Certified copy is fled with the city inspection division. GRE.ASEBNDUSTRL WASTE INTERCEPTOR7EN
GTHE
CERTIFICATE OF E.XEMPDON FROM WORKERS' GREASE TRAP E
COMPENSATION INSURANCE
(TAis annionnadaot he cmnpleted if Ne permit la far one hundrWddlues($100) SEWER-SANITARY-STORM EA.20DPf. FEE
onps.)
I certify that in the Performance ofthe work for which this permt is issued,Islami WATER HEATER WNENT/ELECIR
nm employ any person in any manner so as to became subject to the Workers'CompenentionlawsofCalifomin. Dale WATER SYSTEWMEATINGDate met,N
'z ApplicantNOTICE TO APPLICANT.If,afar meting this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.PT. TOTAL(Amoi become subject to the Workers Compensation proviaiota of the Labor Code,you must
7 fnchwltb comply with such provisions err this pennitshall be domed revoked. FELd
CONSTRUCTION LENDING AGENCY FEE G'
VzIhereby affirm that mere is a construction lending agency for the performance of TOTAL: IC FEC•Othe work for which this permit is issued(Sec309],Civ.CJLenders Name ING E
Lender's Address QTY. MECHANICAL PERMIT
V 1 rectify that I have read this application and ante Nal the above information is
CL, coned.l agree tocomply with all city and county ordinances and ante laws relating to PERMIT ISSUANCE MECHANRIAL FEE
In buildingconswction,and hereby militaries representatives ofthis city to enter upnn the CONS CTION TAX
V 7 above-mentioned pmKny for inspection purposes. ALTER OR ADD TO MECH.
G7 1 We)agree to save,indemnify and kap harmless the City of Cupertino against
Imbilithajudgencnu,costs andexposes which may in any weyaameagelost avid City AIR HANDLING UNIT(TO 10,"CFM)
in camequence of the granting of this pemiL � AIR HANDLING UNIT(OVER I Jose,CFM)
tum of pplicaot/ ontmcm Date XHAUST HOOD(W/DUCI)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 101.000 BTU) Date RcceiprN
Will theapplimiam future building occupant store or handle acardaus rnaterim HEATING UNIT(OVER 100,000 BTU) TOTAL:
to defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)P
El Yes C3 No VENTILATION FAN(SINGLE RESID)
Will Iheapplicoalorfumre buildingoccup rouseequipmentmdevices whichemil
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
hezerdous air aonnmirwds a deftest by the Bay Arca Air Quality Management BOILER-COMP(OVER 1010,0100 BTU)
Couriny pp�F� pp
CI Yes 0N NEW RESIDENTIAL MECH. SQ.FT. IT
I have read Ne Intonations materials requirements under Chapter 6.95 of the
C,lifOmia Health @ Safety Cafe,Sections 25505,25533 and 25534. 1 understand that WAY
if the building does not currently haveatea.,.Nm it is my reaponaibilitym notify the �'� A 2
occupant of the nex iremeno which must be met prior m issuance of a Certificate of
Occupancy. ��
Owner or euWoriuJ agent Dan TOTAL: ISSUEDBY: ( N//NO
OFFIC