26068 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 1171.01 L-E h.L RI AL P12RMI'F NO,
APPLICATION/PERMIT PLUMBING-MECHANICAL. /T�^O[_+ p
BUILDING DIVISION BUILDING PROJF,CPIDENTIFICA'I'ION L U v O
BUILDINGADDRE55: //JJ SANITARY NO. APPLICATION SUBMITTAL DATE
Z.Z,: O' rI� (� / q W.I., UNIT# LOT or �/(i J
OWNI3RSNAME: PHONE. CON'ITtACTOR'I NAME: LIC NO'.
A/r �o ��_ /Ji 1 N/C CON TROL#
RCHDECT'/ENGINEER: LIC NO: T56 ADDRESS: r ❑
W
CONTACT: PHONE: Q1 Y. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG
[IjQ' PLU MF
PERMIT ISSUANCE —_
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDEN'rlAL 1 LOB pli�lattywtnn/�
I lormbyalfinn firm I an licensed underpnrvininnsnf Chapter9(commencingwid, _Q TIM IY/
FOO Section 70001 Division Sof the Bminea and Professions CUJaand my license Isar PANELS
C m full force and effect `
FzW 1: nsc Class Lic.0 55 Sb 11171/ UPTO2MAMPS
vl<a ate ` — Contractor f4— a 201-1000 AMPS
OSQ.FT. OR ARBA IISQ.FT.
ZOrZir—
ARCHITECTSDECLARATION OVER 1000AMPS /'
O'L—O 1 understand my plans shall be used as public records. (C�.'
F ns F JSIGNS ELECTRICAL.
QY�,C Licensed Professional
K
KQ OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
O u1 p,U Lbereby affirm nor 1 am exempt from the CormI License Law lav the
W P.y following rerson.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
Oa which requires a permit in construct,alter,improve,demolish,or repair any structum
to Y� to its issuance.also dims the applicant for such Ito file asi ed smtemetn POWER DEVICES
poor a pv Permit e.t
K<pC that he is Iirenscd pursuant o the provisions of the Contracmh License law(Chapter SWIMMING POOL ELECTRIC
n1QLL 9(commencing with Section 7")of Division 3 of the Business and Professions Code) 11`1 VAALLUAT�ION
,M,,, orthat he isexempnhertfremand the basis for theallegWexcmption.Anyviolationof OUILEfS-SWITChIES FI%'NRPB 2J�/ '_fc)
F_Z Q Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of �--�--f/
not more than five hundred dollars(5500).
NEW RESIDLNTIAI.ELECIR —SQ.FT. STORIES TYPE CONSTRUCTION
C L—o ❑ Lasowrk,and epropeny,ormyemployecswithwagesovhe(Sec.compemmmm,
y3o0 will dolhcwons and the he Contiruci are ra not is License La domod es not
7044,Business
and Professions Cre1c:TM1c Contractors License hew Jsras not apply to an owner of
property who builds or improves themon,and whodoessuch work himselforthrough his
employees,prnviJedthat s.cM1 improvementsaenol inlcndeJuro(fend forsele.IL OCC.GROUP RES.UNITS
Imus, gtbe buildingorimprovement is sold within cncyearo(completion,the owner- A
builder will have the burden of proving that he did not build or improve for purpose of
"ale')' QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ Lns ownernfthe pmpeny,vn eaclusivdyconoaaing with licrosed contractorsm
construct the pmjm(See.II414,Business and Profusions Coale I The Commeams PERMIT ISSUANCE
License Law dors not apply man owner of property who thin Ids m improves thereoq and
wbo conransforsook projects with o emitracra(s)licensed pro Com.—o"
Lit,mor law. ALTER (EA) PEC SUMMARY
❑ I am exempt under Sec. .B&P C for this reasonD T':IDE PEE
BACK FLOW PROI IiN'.DEVICE S
SANITARY Y N
Owner Dae DRAINS-FLOOR,ROOF,AREA.COND. RECEIIT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ Ihcrcby elfimt Nalhaveacenificate ofcorvam mull-insure.ora eenificam of Fl ER RF.CFIT#
Workers Compensation Insurance or amerificd copy therent(Ses.3800.Lab C.)which PARK FEE Y N
cm all employe's un phis permit GAS-EA.SYSTEM-I IN JOUTLETS RECEIIT
Policy# C YO -7-7 '^t7 BUILDING DIVISION FEES
I Q0 CompIIIany GAS-EA.SYS'rEML)VER EA) PLANCHECK FEF,
Wfiled tilied copy is wool,the city impcetinn division. GRLASFJINDUST'RI.WASTE ERCEITOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKER ' ISETNAP SOILS FEE
COMPENSATION INSURANCE It
(This section need notbecompleted ifthe permit is for one hen Mdollars(fl W) -SANITARY ST MEA WFf. ENERGY FEE
or less.)
101 bar in the performance of the work for which this pe it is issued, all HEATER ELECfR
not employ any person in my manner so as to become subja to e W ke PAID
Cnmpenisation Laws of Colifomia. Date WATE STEM ATIN Rmiptp
zz Applicant
Q NOI mm ICE TO APPLICANT IL after making this Cernficmx pue of E .should NE�N.RES )BN'1'IA[,P B. SQ.IT.
(•' .�. becoe subject the Worker's Compensation provisionaofthe rC a ou must
> forthwith comply with such provisions or this permitshell be dee ed rev e B ILU FEE
tilSEISMIC FEE to
0. Q CONSTRUCTION LENDING AGENCY Jok
D z 1 hereby affimt that then is a construction lending agency f or the performance of ELECTRIC FEE
V O the work for which this pctrnit is issued(See.3097.Civ.C.) \
Lender's Name PLUMBING FEE
U" F' 1<ndcrs Address Q'I'Y MECHANICAL PERMIT FEE
U 1 certify that I have read this application and state that the hove Info ar-I is MECHANICAL F.ESRript
correct.l agree to comply with all city and county oriinmces an aaclawsrelatingtoPERMIT ISSUANCIibuilding construction,and hereby aahonire representatives ofthis itymcnterupont GDN$TRGLTID TAX
zNwemetnioned pmperry for inspection p.ryoscs. ALTER OR ADD TO MEC{I.(Wc)agree m save,indemnify and keep harmles.the Ciry o open sin nliabiliticsjodgmenss.corms and expenses which may in any weaccmcamaI said City AIR HANDLING UNIT(TO 10.000 CFM)
in cuosequcnce of the granting of this permit.^! AIR HANDLING UNIT(OVER 10.000 CFM)
ignmure of Applommaor DateEXHAUST HOOD(W/DUC)
PAID
HAYJARDUl1S MATERIALS DISCLOSURE =MP
IT(TO I00.IXq RTU) Dale
Will the applicant or future building occupant store or hurdle horrendous material UNIT 100.1X0 BTU) s t
as defined by the Cupertino Municipal Cute,Chapter 9.12.and the Health end Safety
Code.Section 25532(a)'! N FAN(SINGLE RESIDE
❑Yes ❑No
ISSUA 'i ATE
Will the applicant or future building.acupant use equipment or devices which emit P(IHPOR 100.000 BTU) p�
h dous air contaminants as defined by the Bay Area Air Quality Management MP(OVER 100,0(10 BTU) P A ' D
District?
❑Yes ❑No N'IIAI.MEC{I. SQ.IT. rrR
1 have recd the Instructionsmaterials requirements under Chapter 6.95 of the F^'tl 28 �nrN
California III&Safety Code,Sections 25505.25533 and 25534. I understand that 4
if @e building dors not curt.w have a tenant,that r is my mmeare of r to notify Ne C�/�'
rmcupmt of the rcquirrnmema which mea be met Orion to issuance of a Cenificete of Vf O.y,..
Occupancy. ^ r J �.
i
Ow.m.numhoriscdagent Dae ISSUED BY: ,
OFFICE - 1 L