26950 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OIFCUPERTINO IITIL61N(;-F;LX;(,"fk AI, _ - PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 26950
BUILDING PRO.IRCT HHENTIFICA'I'ION
WILDING ADI SANITARY NO. APPLICATION SUBMITTAL DATE
— e / / UNIT# LOT# —L`I'�_
I ' 'NAME PHONE: C 'SN
NIC CONTROL#
ffHi' EER: LICNO: ADDR S17f V4 J— Y ❑
'ONTACf: PHON&
QTY. ELECTRIC nki�NIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB NIECE
PERMIT'ISSUANCE a 0 /po/E
LI CENSEDCONTRACTOR'Bios of DECLARATION APPLIANCES-RFSIDENTIAI. DHSCRlyf10
OCZ Ihueby elfirLICENSEDCONTRA TORS DELL RATIONcommenting with '
I �as00 Section7000)nf Division Amf be Business and Professions Code,and my license is in PANELS
YU� fall fsrseand at p !
<Z' License Cbrss _ —e3 Lia# `)� UP T02(q AMPS
to Da¢ Cannncbr 201-I(gOAMPS
Z ov K ARCHITECTS DECLARATION 'a; OVER IIIW AMT'S. SQ.FT.BOOR AREA S/gQ.PI'.
0Z�0 I understand my plans shall be ueed.spuhlie records, jj
QLD .I.P SIGNS ELECTRICAL
iRRIy7 j Licensed Professional '
fi'6 OWNER-BUILDER DECLARATION SPECIAL CIRCl11T C.
yyi((Oy V 1 hereby affirm that I am exempt from the Connector's License law for the
IFs- following....(Section 7031.5,Business and Professions Code:Any cityor<Wmy 'TEh1P.METE RPOLR INST.
which requires a permit in construct,alter,improve,demolish,or repair any atremre
r7 prior In its issuance,also requires the applicant for such permit to flee signed sat¢mem POWER .VICES
yil y�p0K that he is licensed purnall to the provisions of the Conneemrs license law(Chapmr
a lio0. 9(mmmencing with Section 7M)of Division7ofthe Easiness and Professions Cade) SW TNG POOL ELECTRIC leg
� yALUU(5"RON
yM, or that he in exempt therefronm and the basis for lhealleged exemption.Any violationof OUTLEfS-SWITCHES-PI%TUNES U/�
t Z 4 Section 7031.5 by any applicant for a permit subjects the applinnt no a civil pewhy of
not more than fee handled dollars($500). _
NEW RF5IDENTIAL ELECfR SQ
❑ I,muownerofthepmp<rny,onnyemployecswithwugesus Neirsolecompensation, .FT. STORIES TYPECONSTRUCHON
M2 will Jo the work,and the structure is not imendedproffered forsale(Sec.1044,Basal
and Professions Code:The Contractors License law does not apply to an owner of _
propery whnbuilJsorimprovcsthcleon,.ndwhodces such wmlhintself,ethrouldh his OCC.GROUP RES.UNITS
nemployees,pmvidedthumsuebimpmvemennsarcnoainiendedorofferemlforsale.If,
however.the buildingor improvement is sold within one yearofcompletion,theowner- TOTAL:
builder will have the louden of proving that he did not build or improve for purpose of
a).
❑ I,aaownerofthepmpeny,amexelusivelyconwtingwiNli..ns orecmrsm QTY, PI.UMBING PERMIT FEE. Iq.00D'I,ONE APN
construct the project(Sec.7644,Business and Professions Code:)The Contractor's PERMIT ISSUANCE
License Lawdoes not apply m an nwnerof propertywhobuildsorimproves thereon,and
whocmumets fanschprojects with.conownads)Iicamedpuccuumthe Contracmr's ALTER-GRAIN&VENT-WATER(EA) FEESUMMARY
License Law.
❑ 1 um exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE SANITARY- Y D N
0- hanotty.ffinallaut
wcer DaN DRAINS-FLOORROOFARFACONDRECEIPT'#, , , .WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ l M1aveacmnifca¢nfronsenuo self-in s..e,oratertifmom.fRECEIPT#
Weaken Compensation p FIXTURES-I'M TRAP
pcnsetion Insurance or.certified copy CJwhich PARK Fl?E YN
covers allemployce' c }{n L RECEIPI'#
#yy� )�Pe GAS-RA.SYSTFiM-I INCA 011l'LLTS
Policy# '•` SL It BUILDING DIVISION FEES
Company II (�L� �• GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ �ifledco6y is herebyfueishad.
LTCentfeJcmpyis Hledwinhnheclty inspersicndivisma. GRFASRdNDUSI'BE WASTE INTERCEPTOR GRADING FEE
CHRTIFICATE OF EXEMPTION FROM WORKERS' GRWRTRAP SOILS PER
COMPENSATION INSURANCE
(This section need not be completed ifnhe permit is fortune hundred dollars(SI00) SEWER-SANITARY.STORM HA.20011'. ENERGY FEE
or less.)
I certify abut in the performance of the work for which this Permit i ' W'1' II WATER HEATER W/VENT/F.LECTR
nos employ any person any manmef so as a become subje n she Work rn PAID _
Coepens.nim"vasof Califenti, Daae WATER SYSTEM/IRFA'1'ING Date R«eipt#
Z Applicant
z 0
NOT ICF TO APPLICANT:If,after m Md M. mifcate of empaiomyousho d NEW RESIDENTIAL PLMH. SQ.FT. TOTAL:
F•kti become subject m the Worker's Co . Ormpmut t.fda bo-CWayoumu ,
> forthwith comply with such P Ion orthiapemnia 11 ad v.kM./ BUILDING ME
W O i NS'I'I,. L13 DI Y /'N.fse SEISMIC FEE
5 Ihcncby effirn shat iso i I ding agency for Ne pe o�u sr' T L: [LF.CIRIC FEE
the work for which this peen 's .3091,Civ.C.
Lcoder'S Name mss
Lenders Address Q`1•Y. MECHANICAL PERMIT FET? PLUMBING FEE
V I certify that 1 have lead thi. chat nun state
t Ne above information is
CI-I comer. Ingreemcomply with all ly and county odinencasand seam lows Blatin PERMIT ISSUANCE MECHANICAL FEE
btildingcommuctinn.anJhereby oma arizerepresenmnivu of this city noenleru the CONSTRUCTIONTAX
V Z also,;antianed pmpemy for h" c'on purposes. ALTER OR ADU TO MIiCIi.
(We)agrte m save,indemnify d keep harmless the City of Cu o against
liabilitice,judgments,costs undexpens swhichmayinrnywayac<f gainhsaid City AIRIIANDLING UNIT(TO io,wx)cFM)
inconscquenecofthegentingof Nis rail.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Applicam4Connecnor Data EXHAUSTHOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I o TUI Data Receiptp
Will dawivilicall or(more buil ing«caplet store or hon lithnaatdma memrial HEATING UNIT(O eR IW.WO BTU) TO
L:
us defined by the Cupertino Man' I Cede.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)1 VRNI']LAI'10 AN(SINGLE RES ID)
❑Yes CZ,
BOLLEN- OMP(7HP OR IOO,IKkI BTUI n ISSUANCE TE
Will ahenpplicantorfuwrcbuil goccupana useequipmemar Aeviccs whichemin T A ' D
manrdnus eii nmtnmrdnnnts u'soJ' ted by the Bay Area Ail Quality Management BOIL -COMP(OVER I00,000BTU) -
DislliclY -
❑Yes N RESIDENT AL NIECE. SQ.FT. IO� 111995
9 •f(](IC
I have read the haaWous materials oliumarro s under Chapter 6.95 of the �JA •L 995
California Health&Safety Code,Sections 25505,25533 and 25534.1 underhandohm CITY
/
if Oma building Anes no currently have vtenant,the it is my responsibility to notify the 5/r'' 1 VI• UUr[Fjl
«capon' f the i h masa be mea prior to issuance of a Certificam of
Oc<upwc /q✓ -
Owner arum Izede t to TOTAL: ISSUED BY:
OFFICE