26337 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPEPERMIT NO. _
BUILDING DIVISION
sloN APPLICATION/PERMIT PLUMBING-MECHANICAL26337
BUILDING PROJECT IDENTIFICATION '
BUILDING ADDRESS -
lo LI lids& Ave,
v� SANITARY NO. APPWCA^ON SUBM ITA DA E
/(�` UNIT# LOT# L�
OW ERS NAM.: 1 \ On PHONE CONT ACTOR'S NAME: //'� LIC NO: 3v14
1617 �` P as,.�' z-.f17-AO 1 N/C CONTROL#
f`�ARCfIITECT .N (NEER: LIC NO: A D-55 2Z Wll'GB) tSFu�CQ TC ❑
.CONTACT: PHONE: -
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE rJL ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
❑yy Thereby affinu that of
3 ofthe
dinss and ittlesof Chapter and mmmcise with / -J- BDF RI
[i1 OWp Senior
hereby
of Division 3 of Ne Business and Pskinssio Cade,and my license is in PANUILS
APPLIA •({�-I\ `fR�11v`
UE fullformandeffe 4k44
M'y yl License Class O Lic.# 1 UP TO 200 AMPS
vFi�on Date - Cemtocmr
201-1000 AMPS
'L O or�; ARCHuse S DECLARATION OVER 1008 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
p y..,p 1 understand my plans shall'be'be used as public records.
IF W�j Lmenud Professranal SIGNS ELECTRICAL x s� B ® � �.A
Yr�j6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISO l (f`9W Ill4. N
iWWi55 L U I hereby affirm fiat I am exempt from the Contractor's License Taw for the
.W w following reason.(Section]031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST. � ) Ill�(Ill u
�1" Cy; which requires a permit m coastmcq alter,improve,demolish,or repair any structure
¢ print m its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
G p. that he is licensed puruant to the provisions of the Contractor's License Law(Chapter
�o 9(cummereing with Section]000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
W-„n or thir he is exempt therefrom and the basis for the alleged exemption.Any violation of --'—
Y Section 7031.5 by any applicant for a permit subjects the Applicant toe civil penalty of OUTLETS-SWITCHES-FIXTURES �.
Gnot more to.five hundred dolloe($500).
m ❑ I,asownerofthepmpetly,ormyemployeeswithwagesastheirsalecompmsation, NEW RESIDENTIAL ELECTR Q.Ff. STORIES TYPECONSTRUCTION
will do the work,and thestructure is not intended aroffered for sale(Sec.7044,Business
and Professions Cade:The Contractor's License Law does not apply to sm owner of
properly who b u tl ds m improves thereon,and who does such work himself or though his
own employees,providedthatsuchimprovements srenotintenled orofferedforsele.If, OCOGROUP RES.UNITS
however,the building or improvement is sold within one year of completion,fie owmer-
builder will have the burden of proving that he did not build or improve for nonose of L.
sale.).
❑ 1,asownerofthe property,amexclusively, contracting with licensed contractor to QTY' PLUMBINGPERMIT FEE FLOOO_ZONE APN
coauthor,the project(See.7044,Business and Professions Cade:)Du Contractor's
License Law does not apply man ownerofpropeny whobuilds orimproves thereon,and PERMIT ISSUANCE
who crematoria forsuch Pmjecr with acontrmcloos)licensediummuant tothe Contractor's
License Lay. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 an exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE O T IDE FE 5
Owner SANITARY Yry
Date DRAINS-FLUOR,BOOP,AREA,CONE RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
. ❑ thereby nsatfirm thatlhaveacenifcateofconsemenof(Is insure.er Lm C.) which FIXTURES-PER TRAP RECGIPT#
of
Workers'Cempemsetionler this
ifiedcopy thereof(Sec.3g00,LebCJ which PARK FEE y__ry_
covers all employee's under this permit. GAS-FA.SYSTEM.1 INC.4 OUTLETS
RECEIPT#
Policy# BUILDING DIVISION FEES
0CCompany
❑ Certified co GAS-EA.SYSTEM-OVER copy is hereby famished. PLANCHF.CK PEE
❑ Cenifed copy is filed with the city inspection division. GREASEBNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(T'his section need not be completed ifthepennitis Bounce hundred dollars($100) SEWER-SANITARY-STORM EA.2001or. ENERGY FEF.
or le s.)
I certify that in the performance afthe work for which this permit is issued,I shall WATER HEATER W/VENT/ELECTR
.or employ any person in any manner so aJp;9rry,4ubjmt to the Workers' PAID
CompensetiQY�ygof Ctry'fomia Date ' 1 WATER SYSTEM/IREATING Dem Receipt#
C) 7-+ Applicant • a z L9
0 NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you shouldENEWRESIDE.NTIALPLMB. SQ.ELTOTALbecome subject to the Workers Compensation provisions ofthe Labor Code,you mustforthwithcomplywith such Provisions or this permit shallbe dcemed revoked. BUILDING FTSE
CONSTRUCTION LENDING AGENCY SEISMIC FEz1 hereby affirm that there is a conswction lending agency for the performance of
U the work for which this permit is issued(Sec.3097,as.C.) TOTAL: ELECTRIC FEE
Lenders Name
Lenders Address MECHANICAL PERMIT FEE PLUMBING FEE
1 certify fiat I have read this application and state that the abuse infommtion is
cored l agree to comply with all city and county ordinances and sloe laws relating mITISSUANCE MECHANICAL FEE
I, buildingcomoruction,and hereby authorize representatives of this city to enter upon the
U above-re ntioned property for inspection lowEres. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(W)agree to save,indemnify and keep harmless the City of Cupertino against
liabilitie judgments,costs and expert which magi any way accrue ainstsaid City AIR HANDLING UNIT(TO 10,000 CFM)
inc a the Stoning of is it.
AIR HANDLING UNIT(OVER 10,000 CEND
ignamr of Appl amucmhoctm TO
EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam We BTU)
Will the applicant or future building occupant stare or handle hazardous material
as defined by the Cupertino,Municipal Cade,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Cade,Section 25532(n)? - -
❑Yes E)NO VENTILATION FAN(SINGLE RESID)
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
Will lheappli mod our as building by the Bay Area Air Quality Management
In p I D
. hnzodous air cnntaminanrs ux defined by the Bay Area Air Quality Menegcment BOILER-COME(OVER 100,000 BTU) P- Pi
District?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. ��� m 1994
I have read the hazardous materials requirements under Chapter 6.95 of the '
Calif ntia Health&Safety Code,Sections 25505,25533 and 25534.I understand that CITY
I,`,,ILL
if the building does not cummoly have a tenant,that it is my responsibility to notify the CIT'1✓be VVtlt„IjB
occupant ofthe requirements which must boffir e met prior to issuance oCenificute of
Occupancy.
e
Owner nramhonzed agent Dam TOTAL: ISSUED BY�