26913 AYYLIGAN I w FILL IN INFOHMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
ISINf;-E1;RCTRTCi(L PERMITNO.
O*CONTA�:
PERTINO APPLICATION/PERMIT PLUMBING G-MECHANICAL n C �'I
DIVISION y BUILDING PROJECT IIIEN'I'UICA'HON G v 1
S: ) SANITARY NO. APPLICATIONSUBMDTALDATE
f(/ / UNITx LOT I i
PHONE: CO R'S NAM i i LIC
NIC CONTROL.
—
EERLIC NO: RE PHONE: - `' '" BUILDING PERMIT INTO
r QTY. ELECTRIC PERMIT FEE
ALJ PERMIT ISSUANCE„ BLDG ELECT PLUMB ECH
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
I OtYZ I herebyaffiro that lam licensed underprovisions of Chapter9(commencing with TOB DESCRIPTION
D]00 Section 7")of Division 3 ofthe Business and Professions Code,and my license is in PANELS
�mu1.. full amettmdeffec '.
c<c.." Littnu Class Li c.p UPT020DAMN w f 1
i is<a Dam Co tmcmr 201'-1000 AMPS
ZO'z �RCH ,CPB OF A ION OVER 1000AMPS SQ.FT.FLOOR AREA $ISQ.IT.
O Z'-0 IunAe dm ssl� a yd cmcoMs.
SIGNS ELECTRICAL
4 � Licrns Pr a anFI.
LDER DECLARATION SPECIAL CIRCIfR/MISC.
KOyU I h y ofmpt from the Contracture License,law for the
oa 3[v.y nllow' g reason.( sines.+seed Professions Code:Any city or county TEMP.METER OR POLE INST.
L'Ee 0 which rtyuira a altos.improve,demolish,or mpu........
S� Y� prior to its issuance,also requires the applicant for such permitofileasignedsmtemem POWER DEVICES
<0 that he is licensed pursuant to the Provisions ofthe Commetm License law(Chapter
d E: F,1 9(commencing with Section 9000)of s Division 3 ofthe Business and Professions Cade) SWIMMING POOL ELE�CIRI VALUATION
0m or he is exempt herefrom and the basis or the alleged exemption.Any violation of OUTLETSSWQCHES FIXTURES
FZa Section 7031.5 by any opplicamPermitfar a Permit subjects the opplicam m a civil penalty of —
'yy 0 .,it mom than five hundred dollars(S500).
o n❑ 1,usownero(Nepmpeny,ormyemployeeswithwagesa+theirsolecompewdon, NEW RESID A FT. gTORIFS TYPE CONSTRUCf10N
will do the work.and the swnureis not intended or offered forsd:i("'cA044,Buslnus
and Professions Code:Fm Contractors License Law does not apply to an owner of
progenywholumIdsorimproves thereon and whodivessuch work himselforthrough his
employms,powidedthatsuch improvements are not itthadedoroffered torasle.IL OCC.GROUP RES.UNITS
however,the buildingor improvement is sold within one yanofcompletion,due, VT TOTAL:
builder will have the burden of proving that he did not build or improve for purinseof
AW
a}
❑ 1,asownerofthepropeny,amexclusivelycon,atingwifhlirenxdconou mlo QTY. PLUMUI GPERMIT fF.E FLOODZONE APN
,xima-am the projem(Sec.9044,Business and Professions CdeO The Commetor's
Liceve Law dmsnouppiytoanownerofpropeny whobuildxm improvesthermrt,end P ISS E
who commets fursuch pmiects with acomracums)licensed pursuant the Contractor's
License law. ALTER-DRAIN&VENT WATER(EA) FEE SUMMARY
❑ 1 am exempt under Ss. .B&P C fen this meson BACK FLOW PROTECT.DEVICE
SANITARY YN
Owner Data DRAINS-FLOORROOFAREACOND, RECEIPI'M
, , ,
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ I hereby affirm that l have a certificate ofcoment to self-insum,or a mnificate of FIXTURES-PER TRAP REMPTM
nrkeri Compensation lnsumnceor o cenifiedeopy thereof(Sec.3800,Lab C.)which PARK FEE Y N
covers aIn u V RECEIPFM
P Y t!aF pe s / GAS-EA.SYSTEM-I INC.4 OUTLETS BUILDING DIVISION FEES
PolicyM ll<m I
Company ;� �� GAS-EA.SYSTEM-OVER 4HA) PLANCHECK FEE
❑ Certified copy is he
Cenified copy is fled with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
Mussection need not be completed ifthe permit is for one hundred dollers(SI00) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I esnify then in the Performance ofthe we&for which this permit is issud,I shall WATER HEATER W/VENDELECI'R
not employ any persnm in any manner so as m become subject m he W.Nars' PAID
Compensation Tawsof Califomia. Date WATER SYSTEMfFUTATING Date Receipt
O z Applicant
z NOTICE TO APPLICANT:If,nor making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
� V] become subjecno the Workers Cnmpens ubt n Provisions of the labor Code,you must
; forthwith comply with such provisions or his pumit shall be dccmdrevoked. BUILDING FEE
Q CONSTRUCTION LENDING AGENCY SEISMICFEE
I hemby affirm that them is a construction lending agency(m ft rformanrce of
U O TOTAL: ELECTRICFEE
the work for which this permit is issued(Su.309],Civ.CJ DU
lander,Name
0 ~F Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE 14
I certify that I have read this application and state that the above information is MECHANICAL FEE
correct.l agree nocemply withal]city end county entireness and mute laws miming to PERMIT ISSUANCE
V z building construction,and hercbye nhonmrtp mntmmasofNis city to enter upon the CONSTRUCTIONTAX
above-mentioned pmperty coon pis ALTERORADDTOMECH.
(We)agrm his
p h s the City of Cupertino egunn
liabilinies,judg ,which yinanyway accrueegninst mai y AIR HANDLING UNIT(TO 10,000CFM)
in conseque ns iso AIR HANDLING UNIT(OVER I0,(MCFM)
nawrt ontracmr em EXHAUST HOOD(W/DDGq PAID
HAZARDOUS MATERIALS DIS SURE HEATING UNIT CIG 100000 BTU) Data Receipt N
Will0 pplicamnor future building occupant s or handle hamrdou,materia] HEATING UNIT(OVER 100,000 BTU) TOTAL: �.
as defined y Ne Cupcnino Municipal Code,Chap t 9.12,and the Health and Safety
Cade,Section 25532(e)]
El Yes EI No VENTILATION FAN(SINGLE RFSID)
ISSUANCE DATE
Will theap0licanwrfumrtbuildingmcupantuseequipmentur devices whichemil BOILER-COMP(JHPOR IW,IXIU BTU)
hmsrdou, in consent namfs to defined by the Bay Area Air Quality Management BOILER-COMP(OVER 1011,000 BTU) A
imtrict^ i'1 D
❑Yea ❑No NEW RESIDENTIAL MECH. SQ.Ff. -I
I have mad the herniations materials requirements under Chapter 6.95 of the F/
California Health&Safety Code.Sections 25505,2.5533 and 2.5534.1 understand that ^
if the building does not currently have a tenant,Nat it is my tespomibilify to notify Ne C / sec
mcupoor of the mquircmemu which most be and prior m issuunce of a Certificate of Uh
Ocuupancy. j
Owner or tot mixed agent Dam TOTAL: ISSUED BY:
OFFICE