26705 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUIL"INEF.I.ECIATCA. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 26705.�f O C
Y5n sI/�-, 1C BUILDING PROJECT IDENI HICAT10N L I J
BUI j;j9ME DRESS: �O\v1' 1 s 1 1�1G UNITp IOTA SANITARY NO. AGPLICATIONSUBMITTALDATE
WNERS NAME: s/� , ` PHpyF=�- CO /� Ctp SCAM LIC NO: NIC CONTROL#
•ARCHITECT/EN INFER: c`7�•\ LIC NO: T11) /gR,. I . . - �.
❑
CONTACT: PHONE:
QTY.: .. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL
Q9z I hereby affirm NU l am licensed under provisionsofamner9bommencingwiN 108 DESCRIPTION
4400 Section 7")of Division 3 of the Business and Professions Code,and my license is in PANELS
FF full if enJ of
C '��'��(�..�l�-�—
FZy( Licen-3�1Lic.p IIP T0200AMPS �+ ri1L•/.
NQti Date Cantmcmr 201-1"AMPS `"TVWVM/VV ssMMMlllfffJJJ
2~OHZ. ARCHITECTS' C TION OVER IOOOAMPS SQ.FT.FLOOR AREA E/SQ.FT.
07 1 understand my plans shall be used a per lic records.
r y i;4ySIGNS ELECTRICAL�d Licensed Professional
y�of6 OWNER-BUILDER DECLARATION SPECIAL CIRCUff/MISC.
KOyF I hereby affirm that 1 an exempt foam the Contractors License Law for the
W 3 u.w following ammo.(Section 0031.5,Business and Professions Code:Any city mcounty TEMP.METER OR POLE INST.
fS C,'
which oxpmo a n permit to conawm,alter,improve,demolish,m repair any..Co.
prisma its ismance.also requires Neapplicrm for such permiuo file a signWau¢ment POWER DEVICES
y) 0 that he is licensed pursuant to the Provisions of the Contractors License Law(Chapter
d 9(mmm,nci with Secllom 7")of Division 3af doe Business and Professions Code SWIMMING POOL ELECTRIC
oty exempt
) VALUATION
or Out h7031.5 by any reGomand the papa for Ne ds gext tho.olissmexemption. civil
of OUTLETS-SWITCHES-FIXTURES
Z< no,Section'than v any applicant for o permit subjects the applicant to e civil penalty of
tmnmthanfroftheprW ,ormyemp. NEW RESIDENTIAL ELECTR —SQ.FT.
yC1 ❑ Lmawnerofdeemuctu,00m of ime.dedmuffedulhw� mrbe(See.campBusinen, STORIES TYPE CONSTRUCTION
will drthewmk,and Nemmmortismm int kende Law
dsnotaply to an Business
and Professions Code:The Convectors License Law uch not apply m an owner of
pmperrywhobuildsmimprovm Nercun,and.hod«ssuchwmk himselfmdwugh Na OCC.GROUP RES.UNITS
wneer,[bebuildivi or improvement
mpr ve sold
within
ne inundWomffered the own If,
huweveatheave'he or den nPmemis anldwithinoneyear a,improve
for thrower- .TOTAL:
builder will have the burden ofprovin8 drat he did not build nr improve(ar purpose of
sale.).
❑ I,usownerofthepso y,smexclusivelyconta tingwithlicensedcano- mono QTLY' PLUMBING PERMIT FEE FLOOD ZONE pPN
construct the project So,.7144,Business and Professions Code:)The Communes
License Law does notapplytom ownerofprupeny whobuildsorimproveethereon,and PERMIT ISSUANCE
whoommacts for smit,ajects withaconsomm(s)licensed pursuanlmma Convanmra V
I
ALTER-DRAN@P,NT-WATER EA
License Lew. (PAT FT?ESUMMARY
❑ 1 am exempt under Sec. ,B @ P C for this roman BACK FLOW PROTECT.DEVICE OUTSIDE
ANITARY Y N
Owner Dem DRAINS-FLOORROOFAREA. RECEIPTp
, , , .
WORKMAN COMPENSATION DECLARATION CHOOLTAX Y N
❑ Thereby affirm that l have acertificate ofcoment to self-insure,or a cmificate of RECEIPT#
Wmkersy'Cyonmpp�eyosgel�ionIt�insuyr1a�pncpe,�r yc�eniGed copy thereof(Sec.3800,Lab C.)which FlXTURLS-PER TRAP FEE Y N
ars aNlC'e--1 0 )S.�� GAS-EA.SYSTEM-1 INC.4 OUTLETS BUILDING DIVISION FEES
P011fy#
Company -- GAS-EA.SYSTEM-OVER 4 TEAT P HECK FEE
❑ );er iEW copy is herebyfamished.tishW.
Certified copy,is filed with the spry impaction division. GREASFIINDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEF.
COMPENSATION INSURANCE
(TNssationneed not be completed ifthe permit is foram,hundred dollars(SIM) SEWER-SANITARY-STORM EA.20017. ENERGY FEE
orless.)
I certify that in the perfomumce ofthe work for which this Permit is issued,l shell WATER HEATER W/VENT/ELECfR
not employ any person in any marmu an as to became subjeet to the Workers PAID
Compensationlawsof Califoram. Date WATER SYSTEM/111EATING Date Receipt
Z Applicant
z0 NOTICE TO APPLICANT,If.after making this Cemificate of Exemption,you should NEW RESIDENTIAL PLMH. SQ.FT. TOTAL:
Fr Gn became Subject to the Workers Compensation provisions of the labor Code,you must BUILDING FEF.
2a , fur with comply with such pmm
visiom or this Permit shell he deced revoked.
UaSEISMIC FEE
a [� CONSTRUCTION LENDING AGENCY
Vz Ihereby afford that there is a construction lending agency for the Performance of
0 the work for which this permit is issued(Sec.3M7,Civ.C.) TOTAL: ELP.CTRIC FEE
Lenders Name
W. U LcWers Address QTY. -; MECHANICAL PERMIT FEE PLUMBING FEE
L) I certify Net 1 have mad this application and Sum that Ne above information is - MECHANICAL FEE
�" 0. correct.l agree to comply with all city and county ordinances atd state laws din ng to PERMIT ISSUANCE
€„"'
Co) buildingcom action,and hereby authorice represenudvesofWiscity create,upontha - CONSTRUCTION TAX
U eMve-mentioned property for impaction pu Ines. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep hmmlesa the City of Cupertino agmen,
Iiabilities,judgmems,cats and expenses which may in any way accrue almost said City AIR HANDLING UNIT(TO 10.000 CFM)
ggqqqq sequence of the granting of this permit.
9Iaw AIR EXHAUST LINGHOOD
(WIDUCNIT ER 10,(100 CFM)
Sim fAppliranr/Commcmr a¢ EXHAUST HOOD(W/OUCO
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Das Receipt#
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER IW,IXIO BTU) TOT
m defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(0'I
13 Yee ❑No VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
Will theapplicnntorfu[urtbuildingoccupanmse Wuipmem nrdevicuwhichemit BOILER-COMP(JHPOR IW,OIIO BTU)
Insertions us,conaminanu m defined by the Bay Area Air Quality Management BOILER-COMP(OVER IN,0(0 RTU)
•
Distort! ❑ 1nI
Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. � A 0 �
I have dead the hazallous materials reyuimments under Chapter 6.95 of the SEP - 21994
if
ulHealth@Safety Cade,Sectionseat,du25573 and 25534,1undersand that
California the boilding does not Safety
currently M1eue Suctions,
255 that it is and 25534,1 m li notify n,
occupant m that reyuirem on,which must Is,met prior to issuance of a Certificate of
Occupancy.
(#'I I7 UI v. T'l a`1
Owner or eathmiud alem Dam ISSUED BY: