26086 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONL
CITY OF CUPERTINO InJILIVINU-ELEM—RICAL PERMIT NO. O
BUILDING DIVISION APPLICATION/PERMIT - PLUMBING-MECHANICAL
BUILDING PRO]F.CIIDENTIFICATION
BUILDING ADDRESS: fi SANITARY NO. APPLIG'DO/N�S�U{BMITTACL/^D-AIL
Q Jaa
1(/�—7 1 V J
r'p LOT p
OWNfiRS NAME: PHONE: L/U$- CONTRACTOR'S LIC NO: NIC CONTROL
• R CID CT/ INE LIC NO: ADD
S: 6/ C r' Hyl
CONTACT: "a, K. y.,. Opp PHONE:pn QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
1 �- „� BLDG ELECT PLUMB MECH
/ telse PERMIT ISSUANCE IQD
LICENSE ONTRACTOR'S DECLARATION Q,$'/3P APPLIANCES-RESIDENTIAL V� JOB DESCRIPTION
pp•Z Ihoodr affmr Nal lam licensW underprovisions of CTepter9(commemm�gwnh
Y100 Section]000)of Division 3 of the Business and Professions Code,and my license is in PANELS j QI�"L�- LYtt ✓n'/V"/
K V4 C full force and effect.
<Z� License Cl Lic.g UP T0200 AMPS (I„f&A r /s-t+0•t — / �Nt.
sN/ Dau Consnc� 201.1000 AMPS
Z.o, ARCHITECTS DECLARATION OVER I"AMPS
SQ.FT.FLOOR AREA E/SQ.FT.
0 Z Q I understand my plans shall be used as public retards.
�N. SIGNS ELECTRICAL
Licensed Professional
OWNER-BUILDER she DECLARATION Col. orION SPECIAL CIRCUI IS
°JO 1 hereby affirmom ConwNet I am exempt frms License law for the
u�3ay which
followingPin.a Permit
to 7031.5,Business and improve,
demolish,.1
An,dry...aunty TEMP.METER OR INSIF.
low'ON; which requires a permit to conswet,nitee improve,demolish,or repair any swemu
Y0 ri«miLLiensedaals.r then titan.(«such ¢omit'.Dl—w— oammem POWER CVICES
p ¢quires PP P 0
apr[ 9tat heboronerairssWpursction Neprovisionsofthe Contncmra and Prelaw(Chapter VALUATION
d qo lt, 9(commrncing with Sation]Wlq of DivisionJaf the Business end Professions Cade) SWIMMING POOL ELECTRIC
p�'^y ordam he is exempt therefrom andthe basis(ort atillegW exemption.Anyviolationof (y,
p.. Q Section 7031.5 by any applicant fora permitsubjecusbeapplicaut to a civil penalty of OUTLETS-SWITCHES-FIXTURES ¢[" I �� S rt6
G not mLasevo Rvehundreddollun 500). NEW RESIDENTIALE•LECTR _SQ.FT. STOR TYPHCONSTRUCDON
❑ Luown rnfthepropuctumi employee ithwe0es ustheiraniecompemedon,
a _ will dothewo ,unJ thaswcsure i. of m ow does not apply
man owneress I
and Profasto nn m tens owdoes not apply m an owner of
properly it int vh d«ssuchwnrkhimulforNroughhie OCC.GROUP RES.UNITS
ownemploy, vi ad Nat uchimprovcmemsarenotime (fared forsale.IL
however.
the
ing oripppppppppp�III0000vemem s01tr1011hin one ye f lesion,theowncr- TOTAL:
lumiderwillh aheburt�6 s;;,z an nojJyyl a m for puryose of
'se1e')' II �qlp`�� QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ I,a+ownerofthe property,emexclusively conlraning wi
an contncmmo
onswct the project(Sec.7044.Business add Professions ode:)The Connacmrs
License Lew tl«snoupply to an ownerofproperry wh06uildsorimprovestherean,and PERMIT ISSUANCE
whocodmicu forsuch projects with a contractors)licensed pursuanuoshe Comr¢mes ALTER-DRAIN&VENT-WATER(EA) FEESUMMARY
License Law.
❑ I em exempt under Sec. D&P C far this reason BACK PLOW PROTECT.DEVICE S '
SANITARY Y
Owner Dale RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOLTAX YN
• ❑ Ihemby affom thntlhaveacertifente of conunuo eelGinsuu,ora certifiuu of FIXTURES-PER RECEIPT#
Workers'Comperuetion Insurance or a«nified copy theoeof(See.3800.Lib C)which PARK FEE Y N
covers dlemploy gu der thi�.pe�n t. GAS-FA.SYSTEM- 40 L S RECEIPT#
policy# l4/1 'I S�— �S BUILDING DIVISION FEES
Company Yrs L— GAS-EA.SYSTEMVVE04(G) PLANCHCCK FEE
Q• Certified copy is hereby famished.
❑ Caddied copy is riled with she city inspection division. GIS' BEANDUSTRL WASTE INTERCEPTOR GRADINGME
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not becompleted ifthe permit is for0ne hundred dollar,(SIf10) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I cenify that N the performance of the work for which this permit is issued,)shall WATER HEATER W/VENT/ELECTR
nos employ any p rears in any manner so as m become subject to the Worker" PAID
Compemadonlaws.f Celifomie. Data WATER SYSTEM/IRRATING Data Receipt#
O z Applicant
Z 0 NOTICE TO APPLICANT:If,afur making this Cenificute of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT.
T
rte become subject to the Workers Compensation provisions of the Labor Cade,you must
a ' fonbwith comply with such provisions or this permit a hall be lamed revoked. BUILDING ME
d CONSTRUCTION LENDING AGENCY R SEISMIC FEE
1 hereby affirm Nat them is a construction lending agency for the performance of
Z - TOTAL: ELECTRIC
U O FEE
the woos for which this permit is issued(Sec.309],Civ.CJ
Lenders Name
U. ~F Lenders AddressQTY. � .' MECHANICAL PERMIT FEE PLUMBING FEE
C IU1 certify she,I have read this application and state that Ne above information is ., MECHANICAL FEE
0. cancer.l agree to comply with all city unit county ordinances and state laws relining to PERMIT ISSUANCE
rn building construction.and hereby ae,hodze representatives ofthis city to enter upon to CONSTRUCI'IONTAX
fJ 'Z aha vememmned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and kap M1armless Na City of Cupertino against
liabilities,judgments,costs and expenses which may in any way memo against said City AIR HANDLING UNI,(TO 10, CFM)
in consequence often granting of skis permit.
AIR HANDLING ON OVAR ilkh CPM)_
Signature of ApplicaMContrecter Doe EXHAUSTHOOD( PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO BTU) Data Receipt#
Will the applicant or far.building eceupmrt none or handle hazardous material HEATING UNIT(OVER 100.00(l BTU)
as defined by the Cupenino Municipal Code.Chapter 9.12,and the Health and Safety
Cale,Section 2 532007 VENTILATION PAN(SINGLE RESID)
❑Yes PN. ISSUANCE DAT
Will the applicanmrfutumbuilding«cupanmuequipmenlordewaswhich can BOILER-COMP(3HP OR 100,000 BTU)
biennium,air comaminenu as derided by the Bay Area Air Quality Management BOILER-COMP(OVER 100,00)BTU)
Dmmtre
❑Yes )a No NEW RESIDENTIAL MECH. SQ.FT.
1 have read the hazardous materials re iummacros under Chapter 6.95 of the NOV �8 ],a
Cnlifomiu Health&Safety Code,Sections 25505,25533 and 25534.1 understand Nat J9
ifthe building does not currently have.lesson.shout is my reapovibility'.oral fy the Cf�. �
acupans of the repay menu which must be et prior to issuers¢¢of a Ceniflcase of {•r y (}+- r
Occupancy. f oa ,f�'
Owneroramhorlx,d gem Du TOTAL: ISSUED BY:
OFFICE