26365 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY ON CUPERTINORM.DING-ELECTRra l PERMIT No.
26365
5
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 3 6
NUILDIN'G PROJEL'I'IDENTIFICATION v.7 U �J
B L��DI1ING ADDRESS:
SANITARY NO. APPLICATIO\NNSSSU�BMITALDATE
/h 1'[ 0 J / to-�Q.�O IJ (/ -e4V 4"NONITIt LOT#
NP SNAME 1'IIONE CONTRACTOR'S NAME: LIC NO.
a rk,e / 33 N/C CONTROL.
ARCHITECT/ENGINEE LIC NO: ADDRESS: ❑
t CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
ELECT P UB MI:CH
PERMIT ISSUAqCE /'
LICENSED CONTRACTOR'S DECLARATION APPLIANCE - ES NT
p6"L I hereby uflnn that l um licensed underprovisions nfairpter 9(commencing with ION DESCRIPTION
W'00 Section 70000)of Division 3 of the Business and Professions Code,and my license is in PA E
,,I-- funnse Cl.-effeet.
Q7� License ClLic.p TO BE
vFi<y
Data Co...,
F y/ ARCHITECTS DECLARATION S SQ.FT.FLOOR AREA $/SQ.IT.
L O y 1 understand my plans shall be used as public records.
Py Fw NS CIRICAL
Qy�'j Licensed Professional
�y�6 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
KOa, 1 hereby affirm that Ion exempt from the Contractor's License Law r the
F
a TEMP.METER OR POLE INST.
t3r-�N following reason.(Section]031.3.Business and Professions Code:Any cityo se
which rcymms a Permit to construct,alter.improve,demolish,or expear sny structure
}� prion.its issuance.alsoeq
requires meapplicaat fmxch permit to files signed sumarm., POWER DEVICES
wC C 0 that he is licensed pursuant to the provisions of Ne Comediennes License law(Chapter SWIMMING POOL ELECTRIC
c E:0 9(cummencing with&eetion]t100)af Division3of me Business and Profession Cade) VALUATION
eKj_y or that he is exempt thcmfmm and the bards for the alleged exemption.Any violation of OUTLETS-SWITCHES- C aRs AA l
F'Za Section 903 LS by any applicant for a permit subjects the applicant toacivil penalty of FIXTURES
t ore than rive hundred dollars($500).
K � Lasownarmfthepmpcny.ormyemployeeswlth wages us tbeirsolecomrameadim, NEW RESIDENTIAL ELECfR _SQ.FT. STORIES I'YPIi CONSTRUCTION
p�„322 will ithe work,and the stmcture isnot intended ornffered for sale(See.]044,Business
and P essions Code:The Commmor's License Ww does wt apply to rn owner of e I' / ` �I I Ill j L
ovionpreperty whobulldsorimprovesthemon.and whodoes such work himselfmthrough his - CROUP ^�• 'S.ON 'S
anployeses,provided that suchimprovements exact imendWoroffcrai(orale.if, l� J CR
huwevar,the building or improvement is sold whiinone yearofcompletion,the merat U L J
builder will have the burden ufpmving that he did nm build or improve for puryose of
sale.). QTY. PLUMBING PERMIT { FEE F ' nPN
❑ I,as wneroftheprop rty,um xclusivelycontmclingwimlicenxdcon=torstn D TE
instruct the project(See.7194,Business and professions Code:)The Contractor's
License lawdoes not apply manownerofproperty wbomildamimprovesmerem,sad PERM]'1'ISSUANCE
whocontrscafnrsucM1 projectswith acontrador(s)IicenxJ pursuantmthe Conuanm'a ALTER-DRAIN&VENT-WATER
LiccnLaw. I A
) ME SUMMARY
x
❑ 1 am exempt under Sea .B&P C for this recon BACK FLOW PROTECT.DEVICE SID FEES
SANITARY YN
Owner RECEIPT p
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR.ROOF,AREA,COND. SCHOOL TAX YN
❑ Ihexbyporeatthmlhvveaccnifiwte of consent mxlf-inure,orecertifcam of FIXTURES-PER TRAP RECEI M
Wohers'Cmmenvatinn lnsumnce orecertified copy thercef(Sec.J&OO.Lab CJ which PARK FEE Y N
tcovcrs all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS REC
PnlicYk BUILDING DI SIO PERS
Company GAS-EA.SYSTEM-OVER 4(CA) PLANCHECK FEE
❑ Certified copy is hereby fumishW.
❑ Cenified copy is filed with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(Thin section need not be completed ifthe permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.20(1FP. ENERGY FE
le".)
I certify that in the Performance ofine work for which mis Permit is issued.)shall WATER IIM'TER W/VENT/F-LECTR
not employ any Person in any manner an as to become subject in the WorkersPAID
Compensation Lawsof Califnnia. Date WATER SYSTEMO`REATING Receiptp
C) Z Applicant
O NOTICE TO APPLICANT:If,.net makingmis Ccnificam of Exemption,you should NEWRESIDE- ALPLMIL SQ.FT. TOTAL:
f" ,�-i become subjeelmthe Wohces Cmmpcnxuon provision of the labor Code.you must
> forthwith comply with such provisions or mis pemail shall be deemed tevoked. BUILDING FEE
ICFEE
(� CONSTRUCTION LENDING AGENCY SEISM
1 hereby affirm that there is d construction lending agency for the performance of
U O r\ ELECTRIC PEE -�
the work for which this permit is issued(See.309
(S . ],Civ.C.)
LT. Lender's Name PLUMBING FEE
C F Lcmder's Address QTY. MECHANICAL PERMIT FEE
i..) I certify that I have mad this application and Stam thin me above information is MECHANICAL FTE
>" correct.l agree tocomply with all city"county ordinances andstam laws relating mPERMIT ISSUANCE
building construction,and hembyauthonu oprexnwn
dvofmiscity to rnter upon Ne
CONSTRUCTION TAX
U Z ularveWO same property for mnify and
keeppurposix. ALTER OR ADD TO MECH.
(We)agree m save,indemnify sed keep harmless me City of Cupertino against
liabilities,judgmems.cost unit expenses which may inanyway accrue against quid City AIR HANDLING UNIT(TO 10.00)CPM)
cnnscque ee I"the gnml' of this permit.
AIR HANDLING UNIT(OVER 10.0110 CFM)
Signature of AppbcunVContractII Wine ill EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.0010 BTU) Date Bacillar 0
Will the applicant or fuwre building occupant smm or handle havallom material HEATING UNIT(OVER 100,000 BTU7 OTAi,:
as defined by Ne Cupenina Municipal Code,Chapter 9.12,and the Heald and Safety
Code.Section 25532(a)4 VENTILATION PAN(SING LH RP,SIDI
❑Yes ❑No
ISSUANCE DATE
Will heapplicam or future building occupant use equiptnemmcn,,iceswhich emit BOILER-COMP(3HPOR 100,0008rU)
ha'mNous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP IOVER 100,000 BTU)
Diatnet] 0 D
❑Yes ❑No NEW RESIDENTIAL MECIi. SQ.FT.
Y I have mad the haaatdous materials requirements under Chapter 6.95 of he
Calderon Health&Safety Cade.Sections 25505,25533 and 25534.i understand that PJA Y 11
if the building does nm cumcndy have a tenant,that it is my responsibility to notify the s
oecupant of the requirements which must he met prior et issuance of a Cenificam of / \)�/•
ccupancy. ks'11Y 1
J cnuny
I Owner or aumonxd ugem Data TOTAL: ISSUED BY: