26589 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPFRTINO -us.siu FRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL C C O A
RUILDING PROJECT'IDR 'II
NTIFICAON o J o J
BUILDING ADDRESS: {//I+/ ►,� ♦ SANITARY NO. APPLICATIONSUBMITTALDATE
2 aDO 54 UNIT# LOT#
OWNERS NAME: PHONE:- CONTRACTORS fyI1 NAM;:
'Du, Cols - LIC NO: N/C CONTNTRROL# l
j ARCHITECT/ENGINEER: LIC NO: ARESS: E]
-7 CAL4Ira"f A A4 Q44L0 At:tV
CONTACT: PHONE BUILDING PERMIT INFO
y'�'' I'♦♦``1'`-p/, `/fps�I /'pq(-� T QTY. ELECTRIC PERMIT FEE
GY�+r„ev v V �k�v11F'I,L /� kJ�� n n BLDG PLUMB PLUMB MF
(� Q ✓L. PERMIT ISSUANCE Z, ,`ly�ll
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
r�tyZ thereby affirm Nal lam licensed underpmvisionso(Chapter9(commencing with
tF�i Op Section](I(1O of Division 3 of the Business and Professions Cale,and my license is in PANELS
W�j, fullfarceanddfect. ��f�_-s''�f/�I?��,-�,s�!�` C ' 4I
F,Z Liecns'Cl Lic.0 II LPT02WAMPS J T/✓`
m Q resit Date Conoacmr I s 1 I 201-1000 AMPS
ZONZ, CHITECTSDECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
0Z
I understand my plans shall be used n public records.
SIGNS ELECTRICAL
� _ 0 8(
QS9dd9',j Licensed Professional
Ey�a'6 OWNER-BUILD ER DECLARATION SPECIAL CTRCUIT/MISC.
X 5;5 1 hereby affirm that 1 am exempt from the Convectors License law for the
1zl3Oa following mason.(Section 7031.5,Business and Professions Cale:Any city or county TEMP.METER OR POLE INST. s /�fy r�
..1 which requires a permit to conswa,eheq improve,demolish,or repair my museum l_IL YO
T� pmom its issuance,tlso requires the applicant forsuch permit to file a signed statement POWER DEVICES
p�j Qp that he is licensed pursuant so the provisions of the Conmmusns License law(Chapter
Naam
o�' 9(comsheing with Section 7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
nay or Nat he is eaemprtherefrom andthe basisfonhe alleged exemption.Any violation of OUTLETSSWITCHESFlXTURF.S
F-Z< Section 7031.5 by any applicant for a permit subjects the applicant to a civil pen - -
penalty of n
five hundred dollars($500).
NEW RESIDENTIAL ELECT SQ.FT, v l STORIES TYPECONSTRUCTION
C p not more than❑ I,nownerofthepmpiny,ormycmployeuwithwagamtheirsolecompensation,
will do the work,.nclthcawctum ie notimendedornffered fonale(Sm.701 Business
and Professions Code:The Contractors License law does not apply as an owner of
property wbahaildsorimpmves therein,and whodaes such wakMmselfor through his
employees.providedthat such improvemensvenotimmndcdorofferedforWe.If, ^ OCC.GROUP RES.UNITS
however,the buildingor improvement amid within one yearoksondeticn,the owner- TOTAL: Y�•/
builder will have the burden of proving that he did not build or improve for purpose of
ante.). QTY, PLUMBING PERMIT FEE
C] I,nowner Mthc propertY.^m<xdusively comruting with licensed convmtontu ------FILO-ZONE APN
construct the project(Sm.7040 Business and Profession Code:)no Contractor's •l
License Lawdmsnotapplytoanowmrofpmpertywhobuildsorimpmvea Nem.,and PERMIT ISSUANCE
who convects for such projects with a contractors)licensedperaomuothe Contractors ere Law.
License
AI:IFR-DRAIN@VENT-WATER IEA) FEE SUMMARY
E31 am exempt under Sm. ,B @ 13 C for this reason OUTSIDE FRIM
BACK FLOW PROTECT.DEVICESANITARYY N
Owner Dote DRAINS-Fl.DOR,ROOF. COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION . , SCHOOL TAX YN
❑ I hereby affirm that l have.emificate ofconentto calf-insum,or a certificate of FIXTURES-PER TRAP RECEIPT#
Workers'Compeation Insurance ern certified copy thereaf(Sm.3800,Lab C.)which PARK FEE Y N
n
coven un
all employee's derthis permit, GAS-CA.SYSTIt INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
[3Cenifede., sherebyfumished. 'L.
❑ Certified copy is filed with the city inspection division. GREASPIINDUSTRLWASTE INTERCEPTOR GRADING FEE NIL.U9
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Edissmtioa nmdnot be completed if Ne permit is for once hundred dolhn($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEF, Vb
orless.)
leen(ythatinthepmfowanooftheworkforwhichthispenitisissued,lshilI WATER HEATER W/VENT/F.LECIR
not employ,any person in any mean.,so as to b err.subject to the WorkersPAID
Cion,mimionlawsof Califomia. Data WATER SYSTEM/TREATING Data Receipt#
O Z Applicmtt
0. NOTICE TO APPLICANT:If,after making this Ceribcatu of Exemption,you should NEW RESIDENTIAL PLACE. SQ.PT. TOTAL-
LI) became subject to the Worker's Compensation provisions of the Letter Code,you most
�i ; forthwith comply with such powtsiomc
ns or this pcit shall M m
claed evoked. BUILDING ME -
a Q CONSTRUCTION LENDING AGENCY SEISMIC FEEILI .01
I henbygifirm Nm there is acorn ion lending agency for the perf.munce of
V O the work for which this pewit is issued(Sec.3097,Civ.C.) TOTAL: 1��, 1^
ELECTRIC FEE I r�
L.endars Name qq
QLeader'a Address QTY. MECIIANICALPEPLUMPING FEE RMIT FEE
CUI really Nm I have reaan
d this application d slate Net Ne above initiation.is FE
MECHANICALE 1
correct.I agree to comply with all city and county ordinances and state laws relating to PERM IT ISSUANCE �'L•(� ` � ��
building constrctiao,and hereby authotize rcpuunntives of Nis city to mtarupon the CONSTRUCTION TAX
U Z above-mentioned Ptolemy for inspection purposes. ALTERORADDTOMECH.
(We)agree to save,indemnify and keep hawlesa the City of Cupertino egaimet
Iiabilldes,judgmemts,costs and expensexwhich mayin any way accrueagainst said City AIR HANDLING IJNIT(TO 110,000 CFM)
in cn cluenceofthe Trani gnf Nis ewit.
GAIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Applican an1bact Date I EXHAUST HOLD OVIDUCT) PAID
IIAZARDO ATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building mcupant stare or handle hazardous material HE ATING UNIT(OVER 100,000 BTU) TOTAL:
n de6nd by the C.,dr t Municipal Code,Chapter 9.12,and the Health and Safety
Code,Sector 25532(a)? VENTILATION FAN(SINGLE RESID)
❑Ya ❑Na
ISSUANCE DATE
Will theapplicauntorfurumbuildingoccupart wasso,dipmennordevicestshich emit BOILER-COME(3HP OR 100,000 BTU)
hazardous air contaminants as defined by the Bay Area Air Quality ManagementBOILER-COMP(OVER 100, 0 BTU) '
00
District? 1
❑Yes 0 N NEW RESIDENTIAL MECH. 111� SQ.Ff. top)
OCT 1 �
I have mud thbe hazardous materials requirements under Chapter 6.95 of the 1994
C.lifomia Health @ Safety Code,Sections 25505,25533 and 25534.1 understand that /.
ifthe building does not currently have a tenant,that it is myresponsibilitym miif fie CII1 OF l+Ui CIYIEi
mcupant of the requirements which must be met polo to issuance of a Cer ificate of
Occupancy.
Owner or authorized agent Dam TOTAL:FEW ISSUEDBY:�i1dIC_�I
OFFICE