26583 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO • •• PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PRIIjEcT UnHaTIPICA'1']ON 26583
BUILDING AD R�:: �.%05-7 SANITARY NO, A/P/P�UCA9'IONSUBMITI'ALDATE
2t. UNIT# VY J LOT# I I .
OWNERS NAME: PHONE: CONTRACTOR'S NAME: LIC NO: N/C lY CONTROha
•ARCHI'IELT/I:NGINC;' LIC NO: Fn\ GALA 1 NX-I4W 7.f ❑
CONTACT: I PJloa BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FGE
N p BLDG ELECT PLUMB M[CH
pS 01Z PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTAL JOB DESCRIPTION
p y.Z I berebyuffirmthall emlicmn dundcrprovisionsof Chapter9(wmmencingwiN LOB
C, Section 90M)of Division 3 ofthe Business and Professions C�and my license is in PANELS i•-
FK U full force and effect. ![ rr J
yay Datenrec�Cnnvacme of 1. 5 UP TO 20ASUPS
8- 201-ItI AMPS
ZOy`- SQ.IT.FLOOR AREA E/SQ.FT.
Z8 tnZ ARCHITECTS DECLARATION OVER T000
CV,
y,Q 1 understand my plans shall be used as public records. SIGNS E CAL Al I s J_0 g
4 J Licensed Professional s
5C 6 OWNER-BUILDERform
ECLARATION SPECIALCI U17/MISC.KOy V 1 hereby affirm than 1 am exemptemptfrom the Cosions Cs e:Any
Law for the
m 3 a y following reason.(Section 9(1]15,Business and Profesrione Code:Any city or county TEMP.METER O LE T ( �q
t�Ooe� which rtquirtaaPermit mcomwct Ater,Improve,Demolish,or repair anYawcture POW2R DEVICES `^I C./
lza 2A AUDI
042>7 prior to its issuancq Also requires theapplicanrfor such perma
it to filesignA statement
W<0 that be is licemed f unuanfte the piovimema Af the Contractor's License law(Chapter
d e 9(commencing with Section70ME.(Division Sof Ne Business and Professimu Code) SWIMMMGPOOLELE �VIALUATION
CG 'orthin obe 131.5 by nhcmfromand the basPerirt stlheallegedexempti an. civilPnaon of OUTLET'S-SWITCHES-I•V(TURES LiLj
CC Section more
n by anY applicant for a permit subjecb the aPPlimnt m a civil Penalty of l l
t ml, than fivehundred dollars ympi
K o n❑ I,mownern(theproperty,army employaswith wagerutheirsalecompcmetion, NEW RESIDENTIAL ELECIR SQ.FT. Ica •:n STORIES TYPE CONSTRUCTION
95: willdo the work,and themmctum isnotiatended.rOffered for sale(See.J044,Business
and Professions Cale:The Contractor's License Law does not apply man owner of
property whobuildr mimproves thereon,undwhodees such workhitmelforthrougM1 his OCC.GROUP RES.UNITS
own emp)oyms,provided chat such impnsvements m not imendM ar offemd forsale.If,
TOTAL: t I• b�)
however.the building orimprov<mem is sold within one yearofwmplaion,theawner-
builJer will hove the harden nfpmving that he did not huild nr improve for puryose of
PLUMBING PERMIT FEE QTY,
'e1e')'
❑ I,as ownerofthe property,am excluaivelycomnnmwtra
ing with liceedneon to FLOOD ZONE APN
consumes the project(Sec.7094,Business and Professions Coded'fheContractor's PERMIT ISSUANCE
License Law does not apply to an owner of property who builda or improves thereon,and Z•v IJ
whocommets forsuch projects with acontractai licensed Formation to the Contractor's ALTER-DRAIN&VENT-WATER(EA) FEESUMMARY
L emon,Law.
❑ OuISIDEPM
BACK FLOW PROTECT.DEVICE SANITARY Y N
Owner Dam pRAINS-FLOORROOFAREAGOND. RECEIPT#
, , ,
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y_N
iel ❑ Ihereby of can that l have a certificate ofconsenl to self-insure.or a aNficate of FIXTURES-PER TRAP RECEIPT#
Workers'Compensation Insurance or a cenifsed copy thereof(Sec.3800,Lab C.)which PARK FEE Y N
coven all employee's under this permit GAS-EA.SYSTEM.1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cenifiedcopyisherebyfumisbed.
❑ Certified copy is filed with Ne city inspection Division. GRL'ASEANDUSTRL WASTE INTERCEPTOR GRADING LLE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP SOILS FEE
COMPENSATION INSURANCE
(Dox section need not becomplefed ifthe permit is foronehundrW dollars(SIM) SEWER-SANITARY-STORM EA.200Ff. ENERGY FEE
orless.)
I certify thin in the performance ofthe weak for which this permit is issued,l shall WATER HEATER W/VENT(ELECTR
not employ any Person in any manner so or m become subject to the Workers' PAID
Compemmionlawsof Califomia. Dam WATER SYSTENUTREAT'ING Data Receipt If
0 Z Applicant
�ZZ-lO NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMICSQ.FI'. TOTAL:
rbecome suhject to the Workers Compensation provisicarri the labor Code,youmuat
forthwith comply with suchproviAmocrmhis permitahall4 claimed revoked. BUILDING FEF. b6 (v
aQCONSTRUCTION LENDING AGENCY 1 SEISMIC FEE
z 't,'•O
1 hereby afford that them isa combustion lending agency for the performance TOTAL.: ELECTRIC EEE
ance of w ,�I
U
U O the work for which this permit it issued(Sec.3M9,Civ.C.) / WIF
Lendera Name PLUMBING FEE:
O h Lender's Address QTY. MECHANICAL PERMIT FEE l
V T certify thm I have reed Nis Nsplicramn and stale that the Abuse information ie MECHANICAL FEE correct lagan m comply with all city mal county ordintrom and mm laws relating to PERMIT ISSUANCE vt•�
V building construction,and hereby authorize representatives ofthis city m enter upon the CONSTRUCTIONTAX
above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. L
(We)Agree to save,indemnify and keep harmless the City of Cupertino against
Iialudities,judgmenu,costs)andexpenseswhichnuy in my way accrue against said City AIR HANDLING UNIT(TO Up"CFM)
fths Food
inin cn of�#rani it. L
AIR HANDLING UNIT(OVER 10,11011 CFM)
Signature of Applicun onrsct I Date EXHAUST HOOD(W/DUC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO that"BTU) Dane Receipt M
Will the applicant or future building occupant snorem handle hem.&-trs material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HPATMG UNIT(OVER 1 W,000 BTU) TOTAL:
Cale,Section 25532(a)'! VENTILATION FAN tSINGLH RESID)
❑Yea ❑No
ISSUANCE DATE
WilltheaMlicantorfummbuildingoccupmtuxegipmentordeviceswhichemit I BOILER-COMP(311P OR FBI,"BTU) a-•
•hazardous air eontmnimms as define)by the Bay Area Air Qualify Mmmgement BOILER-COMP(OVER EXIMB BTU) l]
Du13tmm� ❑Yea No NEW RESIDENTIAL MECH. SQ.Ff. OCTt oq •1 12 1994
1 have read the hmallous materials requiremems under Chapter 6.95 of the Ory yr.
California HnIth&Safety Cale.Sections 25505,25533 and 25534.I understand than
if the building dace not currently have o tenant,that it is my responsibility to notify the UrtK/
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
Owner or amhorized agent Data TOTAL: M.1g ISSUEDBY: —
OFFICE