26841 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO '-FL- PERMO'NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING,-MECHANICAL
BUILDING PROJECT'IUENTINICATION
BUILDING/q/DURESS:Ot-k!2/ �� �����/�y/\ Nb 7Z SANITARY NO. APPLICATIONSUBMrITALDA
L _ / —"s'��' LOT# YJ�If.rS�
OWN�AME: PHONE: ORS ME: #g LIC NO: V s/
D OX Z IS N/C CONTROL#
f ARCUITECUENGINEE : LIC NO: pp �� ♦ i'�� ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACTOR'SDECLARATION APPLIANCES-RESIDENTIAL
O a'Z, Thereby of d That ivisiol 3 ofThe licensed turd ieriosunt.Code,Rod
yboawith JOB DESCRIPTION /
YJOO Section
eandefUivision3of the eusineu and Professions Code,and mylicense is in PANELS p -
FSU full fameund effect. �_►„'1�1\'�-131TJ VL„�„\�
License Cl as L UPTO200AMPS
r~is?y
Date
Conmi 201-1000 AMPS
ZOz' RCHITECTS DECLARATION OVER 1000 AMPS SQ.FL FLOORAREA $/SQ.FT.
r.my plans shall be used nspublic amnesia.OZ-0
r
SIGNS ELECTRICAL n„
Lsemcd Profasmonnl u�t
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. +,
iH aFG. hereby Mas affirm.(Sthat 1 am exempt from the Contradole License Lew for the TER
u�3w+sn following rcawn.(Section]031.5,Business and Professions Code:Any city or county 7T?MP.METER OR POLE INST.
Oee S which requires a permit w consuuct,Alter,improve,demolish,mr repair any structure
a� prior w its issuance,also requires the applicant for such permit to file a signed minament POWER DEVICES DA E 0
i C p that he is licamd pursuant to Ne provisions of the Contracwrs License law(Chapter
X o�' 9Mornmench,with Section 7")of Division 3 of the Business And Professions Code) SWIMMINGPOOLELECIRIC V LVATION
,Mn, in,that it1.5by themfmm Rod'he handsformol a,d,d exemption. civil
of =1N1E7W:M1DENnALELEC7M _SQ.�.
not mutSection ation
rive hmy undred
dollars($500) subjects the applicant wacivil penalty of
� O
not mom than five hundred dollars(5500).
C , ❑ I,nsowncrm(theproperty,ormYemPlmyttswith wegantheirsolecompenseti0n, Q.FT. STORIES TYPE CONSTRUCTION
will do the work,add the sodeltre isnotimmled aroffered forsde(Sm.7044,Business
and Professions Code:The Contractor's License law dors not apply to an owner of
property who huilds orimproves thereon,and who does such work himselfonhrough his
ale.If, OCC GROUP RES.UNITS
however,the building or improvement is sold within oneyenofcompletion,theowmorTAL:budder will have the burden ofproving the,he did not build or improve for purposeofle.).❑ 1,asownerofthepropeny.amexclusivelyconuectingwiNllansedantractonto QTY. FEE FLOODZONE "N
construct the Project(Sec.0044.Business and Professions Code:)The Commustors
Licer Uwdmsnaupplywmownerofpmpenywhobuild mwi vas Ncreon,end PERMITISSUANCE
whocontrectsforsuchprojatawiNaconuaclods)Iium pursuantwthe ControctoeI
Liceme,Law. ALTER-DRAIN&VENT-WATER(G) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason
BACK FLOW PROTECT.DEVICE
SANITARY Y_N
Owns Dow DRAINS-FLOOR,ROOF,AREA,GOND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N_
❑ Ihemby effinn[hetlheve acertificam of cOmm�no self-inaurc,orecenifcew of FIXTURES-PER TRAP RECEIPT'#
Worloor Compensation Insurance or a caddied copy thaeof(Sm.3800,Lab C.)which PARK FEE Y_N_
coven all emplmycc's under This permit. GAS-EA.SYSTEM-I INC.4 0UTLUS RECE1Pr#
Policy N
Company BUILDING DIVISION M❑ Certified copy is hereby famished. GAS-EA.SYSTEM-OVER 4EA)
(
. PLANCI3BCK FEE
❑ C'mr.adcopy is Glad with she city inspection division. GREASEIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION MOM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be complet Brute permit is frrone handrWdollan(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or len.)
I minify that I.the pertornwa of Be work for which this permit is issued,l shell WATER HEATER WJVENT/CLECS,
not employ any person in Any manner so a to become subject to the Workers' PAID
Q Z Compensation Lawsof California. Date WATER SYSTEMnRFATING Data Remind is
O Applicant
NO'T'ICE TO APPLICANT:If,after making this Cenifcute of Exemption,you should NEW RESIDENTIAL PLMIL SQ.IT. TOTAL:
COn became subject to the Worker's Compensation provisions of the Labor Code,you must
•••"`���� ; forthwith comply with such provisions or this Permit shall be deemed revoked. BUILDING FEE
Ri Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby offrn r that these is a ansbmnion leading agency forth,pvformana of
L) O the work fm which this permit is issued(Sec.NeG.Civ.C.) TOTAL: ELECTRIC FEE
Leader',Name
Q U Latrines Addrcsx QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I certify Nm 1 have read this application end state tern Ne above information is
correct. Iagree to comply with all cityand county ordinances and sloe laws relating w PERMIT ISSUANCE MECHANICAL FEE
rF. building construction,and hembyauthodu repmmntativesmfthis city toemer upon the
V Z muse-meminned property for inspection purposes. ALTER OR ADDTO MECH. CONSTRUCTION TAX
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liuhilitic Ju gmenb,costsandexpenses ice mayinanywayacemeegy odd City AIR HANDLING UNIT IT'010,0011 CFM)
on oflhegormingof Nis rain. // � t
VJ� AIR HANDLING UNIT(OVER IO,IIOp CPM)
Sig at of o r Dam EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Ra_eiptN
Will the Applicant or fuwre building occupant slow or handle humorous material
as derinW by the Cupertino ATI
Municipal Code.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER I BLOW BTU) TOW
TAL: ~
Code,Section 25532(a)Y
11 Yet, 0 N VENTILATION FAN(SINGLE RFSID)
BOILER-COMPOITPORIOg000BTU) ISS DA
TIT 1%,147T
Will the,cont aminantsor I,building by the ay AMR Air Quality es Management W Ar 0
hazardous air contaminants as defined by the Bey Area Air Quality Management BOILER-COMP(OVER 100,fN10 BTU) v�#V
DistrinP �,(11r(��'
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.IT, /xG
1 have mod the hazardous materials rcyuirements under34Chapter 6.95 of the Cq r`r 8 1994
Cdifmnia Health&Safety Code,Sections 25505,25533 and 235 .Iunderstand Net
if to building does not comm
al,have A tato,he,it is my resperadidity in notify the yy-
acupant of the requirements which must b,met prior to issuance of a Cenifcne of e
Occupancy.
Owner or amhonzed agent Dam TOTAL: ISSUED BY:
OFFIC