26286 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OFCUPERTINOt D. 1 .-F. ,RI AL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL A A O C
BUILDING PROJECTIDENTIFICATION L L O U
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
CL ti UNIT# LOT#
OWNERS NAME: PHONE: CONTRACTOR'S NAM LIC NO:
v r _ ry/C NTROL I
RCIII 4 6GINIER: LIC NO: ADDRESS: ❑
Sfone Zoe
CONTACT: j%M �4 n10 PHONE:�!.) 93_y7,,QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
V BLDG ELECT PLUMB MEC
PERMIT ISSUANCE ❑ ❑ O
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL 108 DESCRIPTION
Q=Z Ihereby affirm that l am licensed umlerpmvisim.ofC pmr9(commencingwith
J00 Section]00(d.f Division 3o4 Ne Busineu and Profesam.Cade,and my It..is in PANELS
q LL full farce vnd cIT L r
G V OP TO 200 AMPS
License Cl�aJss � ic,p
vf—i W Dme T .�Comrxetor 201-LOW AMPS
Z Ov`rsi'� ARCfIITEC rs DECLARATION OVER I"AMPS
SQ.FC FLOOR AREA S/SQ.FT.
O N"C I understand my plans shall be used as Public records.
SIGNS ELECTRICAL i
Licensed Professional OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. t" I�
°�0a I hereby affirm that I am exempt from the Conttactar's License law far the •� ��
W 3 LL HQ following reason.(Section]W 1.5,Business and Pmfessiorm Code:Any city m county TEMP.METER OR POLE INST. •, I��/ '•1I t
C u'Oy J which inquires a permit to consume.a)ter,improve,demolish,or repair any.weure �.r J L' �.%� II i'�
T7 pnmto its issuance,alsompius the applicant for such Moral to file a signed statement POWER DEVICES
u_p0 that he is licensed pursuant to the provisions of the Curvatures License law(Chapter DATE ON
o�' 9(commencing with Section 700K)of Division 3of de,hBusiness and Professions Cade) SWIMMING POOL ELECTRIC
�y or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWICHES-FIXTURES
4 Section 7031.5 by anyapplicantfor.permitsubjec.the applicant to v civil Penalty of
not more then five hundred dollars(x500).
0 NEW RESIDF.NTIALELECTR _SQ.FT. STORIES TYPECONSTRUCHON
❑ Lthe wrk,andeesmatu,ormyemplryedorofcedforshei(sole compereoness
a will do and the heCoeisnotimrndese Law
hot apply
to an owner of
and Professions Cade:The Comractor's License Law does na[apply m an owns of
properywhobuildsmimproves themon.and whndoes such workMmselforthroughhis OCC.GROUP RES.UNITS
van empl oyms,providedd at such improvements am nos i mended or offered for sale.If,
however,the buildingmimprovement is said withinoneyearofrompletion,the owner. TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
❑ 1.>ownerofthepropeny.amexdusivdyconvatuingwiN licenaedconvacum to QT.YPLUMBING PERMIT FEE FLOOD ZONE APN
mastmct the project(Sec.]Bad,Business uul Professions Cde:)The C.nt—.,.
License Lewdmanot Vplym an ownerofpropenywhobuilds orimproveahereon,and PERMITISSUANCE
whrmntrvctsforsuchprojects with acontractorad licensed pursuant to the Contractor's
Liace Law. ALTER-GRAIN&V[NT-WATER(EA) FEE SUMMARY
❑n1 em exempt under Sec. ,B&PC for this mason BACK FLOW PROTECT.DEVICE
SANITARY Y N
Owner Dam DRAINS-BOOR,BOOP,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ I herebyaffirm that l have o cerifcam cleanses to self-insure,or a moificam of FIXTURES-PER TRAP RE.CEIPI'N
Workers'Compensation Insurance or a certified copy herself(See3800,Lah C.)which PARK FEE Y N
f• coven all empbyY'surtdarthispe�b2619/ GAS-EA.SYSTEM-1 INC.d OUTLETS BUILDING DIVISION FEES
Policy# 77 YY 11 YY dd
[I Certified copy is hereby famished.eY GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ C
Ik Certified copy is filed with the city inspection division. GREASFJINDUSIRL WASTE INTERCEPTOR GRADING FEE
/ CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This mtuionneed ambe comncd ifthe permit is forons hundred dollars(S 100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
Lew")
I certify that in the performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to become subjet to the Workers' PAID
Cmnpermmion Lawsof Calihorn. Data WATER SYSTP.M/IREATING Date Receipt#
O z Applicant _
z 0 NOTICE TO APPLICANT:If.spur making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,IT. TOTAL:
V) became aubject to tine Workees Compensation provisions of BIN Tabor Cd,you mon BUILDING FEE
a > forthwith comply with such Provisions or this permit shell be deemed revoked.
FSI Q CONSTRUCTION LENDING AGENCY SEISMIC FFR
z I hereby affirm that then is a construction lending agency for C
the performance of - TOTAL: ELETFE
RIC E
L) O the work for which this permit is is...d(Se.3097,Civ.C.)
Lender's Name
IT. I~ Lmdtes Address QT-Y,'. '',( �MECHANICAL.PERMII, FP.E PLUMBING ME
V 1 certify that I have read this application and state that the above information is t'
emoort.l agree m comply with all city and county ordinances and state laws reining to PERMIT ISSUANCE MECHANICAL FEE
VV) building construction,and hereby authoriurepresentatives ofthis city m enter upon the CONSTRUCTIONTAX
V Z above-memi,med property,for inspection P.W... ALTERORADDTOMECH.
(We)agree to save,indemnify and kap bmmless the City of Cupertino.,Was[
lubiliricajadgmerts,cos.and expenses which may in say way accore,rd..,said City AIR HANDLING UNIT CFO It"CFM)
consequence orthe granting of Nie permit.
AIR HANDLING UNIT(OV E0.10,gp CFM)
Signamm of Applicant/Cmuraaor Date EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO ifflM BTU) Date Receipt#
Will the applicant or fdmre building occupant store or handle hmurdoux material HEATING UNIT(OVER IIXI,OfI(1 BTU) TOTAL:
us defned by the Cuprinn Municipal Code,Chapter 9.12,and the Health and Safety
Cde,Section 25532(a)? ✓✓ VENTILATION PAN(SINGLE RESID)
11 Yes to No
Will theappfcanmrfumm buildingoccupant tawequipmentardeviceswhich emit BOILER-COMP(311P OR IW,ODO BTU)
hnvadeaus air contaminants as coined by the Bay Area Air Quality Managammt BOILER-COMP(OVER IOg0008TU)
District]
❑Ye I Lhl. NEW RESIDENTIAL MECH.—SQ.FT. APR gI ell 2 6 19V
UU
1 have red ara
the hrdmaterials requirements materrequirements under Chapter 6.95 of th �[
California I IraBA&SafetyCode,Sections 25505,25533 and 25534. I understand that
ifthe building does not currently have Braman,that itis my responsibility to notify the
occupantDG. I PECTIO ARTMEHT
rrems of the re,.newhich an
must he met prior to issuce of a Ceni is to of
OcMy� �, y=za-9�G CI F U R
Owner m au its nod agent Dam TOTAL: ISSUED BY:
OFFICE