26225 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - IH MARC-F.MIlTCAI, PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL nQ nC
BUILVING PROJECT IDENTIFICATION G v G J
BUI NO ADDRESS: SANITARY NO. APPIJCATIONSUBMHTALDATE
Y N , UNIT# LOTp 1 }
O C RACfOR'SNAME
1Ij r soo LIC NO: N/C —` CONTROL#
•ARCHITEC(ENGINHER/:) LIC NO: A ESS:C7 1 InL ❑
lag Fmm ay.
CONTACT: - -PHONE: - QTY. IiLECTRIC PA.RMIT Flife BUILDING PERMIT INFO
p `SS � " HLDG EL� PLUMB ME 1
-
PERMIT
ITISSUANCE 7 \IT/�I
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DISCRIPfION
qxm d z thereby affirthat l em licensunderprovisionr of ChopIm9(c .handed it with
WOEhn]Wdf Division3of the Business odd Profession Cash,end myliernu lain PANELS
[❑� failfull fa
rK W
orce end ffU� �•rg.
pQ„ZW License Class Lic.p 6 0 IIP TO 2M AMPS
D.
Date Cnnwctm- 201.1000 AMPS
I" zARCHITECTS DECLARATION OVER It]OOAMPS S FT.1' $/SQ.IT.
zO=FW I understand my plansshall heneedas public records. A 1
F❑❑mal SIGNS ELECTRICAL
aa ',j A Licensed l'mfessamid fk /t f,�] II p
erJ uiy lLl''6 OWNER-BUILDER mDECLARATION SPECIAL CIRCUIT/MISC. t. IY,\VI Y7 YC� I'IiJp 1
iyyiS5O aF I hereby a.(Se that 131.exempt from Ne Connennr's License Law for Ne
following rcestm.(Sadion]031.5. T F1
Business and Professions Code:Any city or county TEMP.METER OR POLE NST.
which requires a permit to construct,alter,improve,demolish,or repair any structure E QT
�j P:Z poor to its issuance,meoreyuira meappliceat forsuch Permitto file a signed statement POWER DEVICES
yu"�J CO Phut he,is licensed pumnun to the provisions of the Contractor's License Use(Chapter
n-aO ff 9(commencing with Section 700l Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC /''� /�V�ALUATION
W-.y orthat hei.s exempttherefrom and me basis for the alleged exemption.Any violation of OUTLETS-SWITCHES.FIXTURES 12 ` / y� ��
F- 6
Section 7031.5 by any applicant for a permit the applicant moa civil penalty of .l
not more,hun five hundred dol lars($5W). EWREIDETALELEJS . T.❑ rsulioompemedon
S'IGRIHS TYPECONSTRUMION
y _ will do the,ork,and the structure is not intendedormffired forsale(Sec.7W4.Business
and Prafessians Code:The Contractor's License taw does not apply to an owner of
property who buidsorimprovestuereon,endwhodoessuch work himaelrorthiough his OCCGROUP RES.UNITS
wacmployces,providedthat such lmprovemenuarenat intendedoroffcredforsale.If,
however,the building or improvement is sold within one year ofcompletion,theowner
builder will have the harden M proving that he did not build at improve for purpose of
axle).
CII,as ownerorthe property,amexclusively conducting with licensed contractors to QTY, PLUMBING PERMIT FEF. MOOD ZONE APN
dnstmct the podpact(Sec.7014,Business and Professions Code:)The Connector's I _
License Lawdoesom apply to an ownermpraperty who builds or improves thereon,andPERMITISSUANCE
who contracts forsuch projects with acounrector(s)licensed purement to the Contractors
License Law. ALTER (PA) FEE
SUMMARY
❑ 1 am exempt under Sec. ,B&P C far das resson PACK FLOW PROTECT.DEVICE SID :ES
SANITARY Y N_
Owner Duro RECEIPT 0
DRAINS-FLOOR,ROOF,AREA,CONU.
WORKMAN COMPENSATION DECLARATIONSCHOOL TAX YN
• ❑ Ihemhy effum thatlhaveettnificam of wnum mulGinsurc,oracmi0cme of FIXTURES-PER TRAP 7 RECEIPrk
Workers'Compensation Insurance or acidified copy nodeof(See.38M,Lab C.)which PARK FEE Y N
covers ell cmployece Rader this ismmit. GAS-FA.SYSIEM4 INC. OUTLETS RPCEIIT'p
Policy a BUILDING DIVISION FEES
Company GAS-F.A.SYSTEM OVER 4(EA) PLANCIIECK FEE
❑ CenificJ copy is hereby burnished,
❑ Ccnilid copy is Bled with Ne ciy inspection division. GRP.ASEIINDUSTRL WASTE INTERCEPTOR GRADING THE
CERTIFICATE OF EXEMPTION MOM WORKERS' GREASETRAP SOILS FET,
COMPENSATION INSURANCE
(This menidnnednm becompleted ifthe Permit is for one hundred doll8rs($IOM) SEWER.SANITARY-STORM EA.2MFT. ENERGY FEE
or less.)
I certify that in the pMomuneeofthe.,it for which this .it is issud,Ishall WATER HEATER WNENT/ELECTH
not employ any person in any madder so as to become subject to the Workers' PAID
Compcnsmionlawsof Califrmia. Dam WATHR SYSTFM/IREATING Dme Receipt It
7-a Applicant
z�7�-1 � NOTICE TO APPLICANT:if,after andsm,Nis Certificate of Exemption,you should NEW RESIDEMIALPLMB. SQ.17, TOTL:
F' q] become subject to the Worker's Compensation Provisions of the Labor Code,you must
Fri F-a fmnhwidh comply with such pm,ieionx air this permit shall be domed revoked. BUILDING IEE
ow Q CONSTRUCTION LENDING AGENCY SEISMICFEE
Z) z I hereby affirm that them is a construction lading agency for the performance of
L) the work for which this permit is issued(Sec.3097,Civ.C.) T ELECT
Lk. Lenders Name
O 1-' Leaders Address QTY. MECHANICALPrRMIT FEE .5"k BIN FEE47.4
W I certify Net I have red this application end shim that the above information is
0. correct.lagrwmermplywithallcitymme..myordinancescomi,mealewsrehurritd PERMIT ISSUANCEMECHANICAL FEE /a
fA building concoction,end hereby authorize representatives ofthis city to enter upon the
U ebmve-mentioned property for inspection pmposes. ALTF.RORADDTOMECH. CONSTRUCTIONAX
00
(WR)agree m save,indemnify Rod kers,hernleu the City of Cupertino against
liabilities,judgments.costs cod expenses which many way urinate against said City AIR HANDLING UNIT(TO 10,000 CFM)
inert - seance ofthe ngofthis
/a AIR HANDLING UNIT(OVER IO.WO CFM)
tenure of ApplicanUCarddcu �F Dam EXHAUST HOOD DVIDUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEA-1[NO UNIT('1'O 100,000 BTU) me Receipt N
Will the applicant air future building occupant store or handle hazardous material HEATING UNIT(OVER I W,OW BTU)
as defined by the Calandra.Municipal Cole,Chapter 9.12,and the Health and Safety
Cale,Section 32(a)+
❑Yes ❑No VENTILATION PAN(SINGLE RfSID) t
Will thea licuntorfutuubuildin occu ,use BOILER-COMP(3HPOR 100,000 BTU) ISSUANCE DATE
pp g pan equipment duality eswhichemid
hsaardous air cnndminams as defined by the Bay Arca Air Quality Managemmmt BOILER-COMP(OVER 1(0,000 BTU) p� p
A 0
D
�mistodP ❑Dy. ❑Nn NEW RESIDENTIAL MECR. SQ.FT. P
1 have read the hazardous mamdal,requirements under Chapter 6.95 of the
Califnria Health&Safety Code,Sedions 25505,25533 end 25534. 1 understand Nat APR --1 1994
if dire building does not currently have n tenant,that it is my manonsibilay to amity the
.cap.,ser the mquircanams which mus,he met printed lissome,of a Cedemifiwm of Ify
Occupancy, ,
Owner or authorized agentDo¢ T L: ISSUED BY:
OFFICE is