26451 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
-E - PERMIT NO. 26451� ���
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F CUPERTINO APPLICATION/PERMIT PLUIL"INc-MECHAMCAI.
INC.DIVISION BUILDING PROJECT IDENTIF'ICAI'SON
BDDRESS: � / ��{$��.� SANDARYNO. APPLICATION SUBMITTAL DATI
3 3 A/ NIT# LOT at
OME: PF{fal .� a O ACfO@'g AME:s I 1 �
(�D T$' 1( 'N` N/C CONTROL=#
AS GINEER: LIC NO: AD R
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13 t4tDo d Dr Rrole 94
AVTTAACL Pro �f QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
�G� `l—"�G P PERMIT ISSUANCE ' B� ELECT PLUMB MECH
LICENSED CONTRACTOR'S D[ A ATION APPLIANCES-RESIDENTIAL
GCZ I hereby affirm that l am licensed underpRvisionsof Chapmr9(commencing with JOB DESCRIPTION
�s1,00
Serious 700(b.1'Division 3 ofth,Business and Professions Code,and my late.is in PANELS
W'u B Band effect.
<,— UP IIP TO 200AMPS _
en,G'y ate Cunlraelor�a[ 201-IMAMPS
ZOyz ARCI{ITECTSDECLARA OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.Er.
O Z t O 1 unJeraanJ my plans shell be used as public records.
F, F•m SIGNS ELECTRIC
Q Y j Licensed Profexiond
ory.CQ OWNERBUILDERDECLARATION SPECIAL CIRCUIT
KOaU I hereby affirm that 1 am exempt from the Conlrecmrs Licenu Law for the
m3 ay following rea,son.(Section 7031.5.Business and Professions Code:Any cirymcounty TEMP.MEfER INST.
h'.LLJ� which rcyuircv a permit to cmwwcl,altar,improver,demolixh,or repmr any swcturo
Kn<� prionn its issuance,alsoreyuires the applicant mrsuch pmanitte,file a signed moment POWER DEV
W K Q O that he is licensed pursuant o the Provisions of the Contractor's License Law(Chapter
dXe� 9(commencing with Sio,mn7000)of Division 3 ofthe Business wal Pmfessious Cade) SWIMMING POOL ELECTRIC VALUATION
Ip_w or that he is exempt therefrom and thth
e basis far e alleged exemption.Any violation of
lFZQ Section 0031.5 by arty applicant for a permit subjects the applicant to.civil penalty of EIS-SWITCHES-FIXTURES �
C notmmemanfivebandreddnEars(S50(0).
W m ❑ l.asowneroflhe t NEW RESIDENTIAL ELECTR —SQ.FT.
proper y,nrmyemployeeswitbwagesaslhdram.compensation, STORIES TYPB CONSTRUCTION
a _ will do-the wons Coale:and heContisnotintendese La c doesed not
apply.?044,Business
and Professions Cade:The Contractor's License Lew does not epPly to an owner of
p nywhobuildsorimpmvesthereon,aodwhodoessuch work himslfor0vough his
own employees,Provided that such imprevementsmenotimendedoroffered forsde.If,
OCC GROUP RES.UNITS
however,the building orimpmvemem is sold within one year of completion,the owner.
builder will have the burden of proving that he did not build or improve for purpose of
'tilt.).
❑ I,eowneroflhepwpeny,amexclusivelycontractingwimticensedcontracwnw QTY. PLUMBING PERMIT FEE FLOODZONE APN
o iamt the project(Sec.7044,Business and Pwfesimis Code:)The Conuacwrs
Licenu Lawdoesnolapplyl-an-wowifloperrywhobuildsmrimpwva Hereon,end PERMIT ISSUANCE
whecantmets forwch projects with aconm earrO)licensed pursuant to For Cemen tori
License Law. ALTER-DRAIN&VENT-WATER(EA) PEE SUMMARY
❑ 1 am exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N_
Owner Dao DRAINS-FLOOR,ROOF.AREA,COND. RECEIPIYI
AAM I
WORKMAN COMPENSATION DECLARATION RATION SCHOOLTAX Y N
❑ Thereby affirm thallhavicecenifi<am ofconum to self-insure,ore«nificam of
Workcrs'Compensution lnsumnce nracertifirA co thermf(Sec. FIXTURES-PER TRAP / RECEIPTp
PY PARK FEF, N
ars ell em playee'sandenldx c GAS-EA.SYSTEM-1 INC.4 OUTLETS eC k
PolicyM L I I ION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCI
❑ Certified copy ish rtby famished. w
❑ Cenifiedcopy is 1'i with the ciry impel ndivisi n. GREASE/INDUSTRL WASTE INTERCEPTOR GRADIN
CERTIR An r ORKERSGREASETRAP
OM 1 N SOILS FEC
(Thissectionneedn lace di the,manitisforonehund dYYrtx($Iugh SEWER-SANITARY-STORM EA.200FT.
or lesl ENERGY FEE
s /�
I certify that in me pe . o e xR��or whty/ ni Ord,I shell WATER HEATER WIVENT/F.LECTR
not employ any person in m
y m t "A1 tat to the Workers' PAID 176Compensation laws of Cdifo la, ate WATER SYSTEM/IREATING
7-. Date Serve r
0 Applicant
'Z 0 NOTICE TO APPLICANT:If,aftXQa1d.,this Cenificate NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
^� Ge, become subject to the Workers Com a bat Cade,youmust
forthwith comply with such previsions or this permit shall be doemed revoked. BUILDING FEE
►�
per, Q
CONSTRUCTION LENDING AGENCY SEISMIC FEE
z work
far which
that them is aswdl(Sec.3lending agency for the performance of
(, O the work far whicM1 this pertnit is issued($a.3(19],Civ.CJ L: 0,`— ELECTRIC PEE
Lenders Name
0 U tenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE Gn
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city sand county ordinance and slate laws nelaung to PERMIT ISSUANCE MECHANICAL FEE
_ building construction.and hereby aothonre representatives ofthis city to enter upon the
U Z dbe,e-mamboed prm,dy for inspection pwpamc, ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree to save,indemnify and keep beardless the City of Cvpenino against
Iiabililies.judgmenn.costs and expenses which may in my way accrues don said Ctry AIR HANDLING UNIT(TO 10,000 CFM)
int uein olibel, migofthispermit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Sig meof App lb,m Coanchor Dale EXHAUSTHOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 1000)0 BTU) Dale ReceiplM
Will the applicant or future building oecureant store or handle hazardous material
m defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety HEATING UNIT(OVER I 011,00g)BTU) TOTAL:
Code,Section 25532(a)?
❑Yea 0 N VENTILATION FAN(SINGLE RFSID)
Will the apBOILER-COMP QHP OR 100,0011 BTU) ISSUANCE DATE
plicantorfurore building occupant useeyuipmcmordevices whichemit pp
AIM I
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER- ( P A t
District? COMP OVER 1 W,WO BTU)
❑Yes ❑No NEW RESIDENTIAL MECH, SQ.FT.
I have read the hazardous n-len-a rnyulrcnmmta under Chapter 6.95 of the AUG 1 g �ggq
Califomlu Health&Safely Code,Sermons 25505,25533 and 25534. 1 understand that
if the building does rwt currently have a tenant,that it is my responsibility to notify the
occultist of the requirements which must be met Poor to isms ve of a Cenificate of CI I Y Vf NUf CI'11 f d
Occupancy.
Oarm,or anlboosed agent Date
ISSUED BY:
OFFICE