26083 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO '-�T� PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAI. 26083
.BUILDING PRO,IECI IURN3'IFIGAT'ON. .
BUILDING ADDRESS: Agl is_s �y'� SANITARYNO. AAPPS/LICAATTIIONNSU/B�gMI[TTA'LDATE
RolV UNIT# lam- VLOTTJ#
OWNERS NAMR:M�, . PIIONE: O COWR CTO NAME: LIC NO• L l l
fC�y,. � NIC CONTROL#
'S ARCHITF.CI'/ENGIN• LIC NO: A RESS:/JQ p14,�, J Jct Cl
CONTACT:
PHONE, y 4i7 7
QTY!y• i, xEhEw IRI ERMIT ' ` �gU 'BUILDING PERMITINFO
UPI,'1+tr� � '' '�-" -' BLDG ELECT PLUMB MECH
OJ PERMITISSUANCE )9 E] El 13
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL 4S I._ LOB DESCRIPTION
OC2 I hercbyaRom that l am licensed underprovisioma'Chatneel) ommrncingwiN rl0'4'�hv .n '
�i100 Section J(00)a(DividonJofNe Business and Professions Cade,and mylicenu is in PANELS 11-Qn a12
K V full forte and eif)t. C`1"r'
FZW License Class Ln.N UPTO 200AMPS II
rn6y DateContrmror
F y Z ARCHITECTS DEC RATION Y. S OV- 1 AMPS AN SQ.FT.FLOOR AREA S/SQ.FT.
OZ�.. 1 under and my til...hell be used its public recmda OVER 1000
<yM_i Licensed Professional SEE SELF
C
�6 OWNER-BUILDER DECLARATION SPECIALCIRC /MISC.
4XOaU 1 hereby affirm that 1 em exempt from the Cessions Co License law far the
W 3 4 y following reason.(Section 703 L5,Business and Professions Code:Any city or aunty TEMP.METER OR POLE MST,
which requires n permit m construct,cher,improve.demolish,m rtpeir any swc[urc
h9<0
>-� prior to its issuance,also reyuiras the applicomfor such permit to file a signed statement POWER DEVICES
hS Q O that he is licensed pursuers to the provisions of the Contmmo's License law(Chapter It g
a• K 9(commencin with Section]" f Division 3 of the Business and Professions Cade SWIMMING POOL ELECTRIC _
op, (commencing )o ) VALUATION R�
-,y or that he is exempt thcrcfrom and the basis for the alleged exemption.Any violation of OUTLETS SWITCHES-FIXTURES ' a�s d0
QSection 7031.5 by any applicant for a Permit subjects the applicant to a civil proudly of ♦ L.tN
C not more than five hundred dollars($500). 3
as property, Y P Y 8 penes NEW RESIDENTIAL ELEC R _SQ,FT. STORIES YPF,CONSTRUCTION
p ❑ othe wrk,undthe
eis emtoenwithweee.the(Sce.cum tion, )
will Professions,ande:1hemmisnot's License La ercoes not apply on
Business p 1,f^I
property
Professions Cade:mpr Contractor's std who res Poen not apply m rt owner of e1 V 1�
properrywyces,pdsrrimproveschimpr,andwhu bnsuch wchdor selfor threale.Ie d�
emplryees,pmvidetl that each improvemema ore notintendedornffercd forsele.If, OCC.GROUP RES.UNITS
however,the buildingor improvement is sold within one yearn(completion,theowner. TOTAL: Ae,3
builder will have the burden rf proving that he did not build or improve for purpose of VV
sale.).
❑ I,as owner ofthe Property,umexclusivelyconvacting with licensed mount to QTY. PLUMBINGPERMIT FEE FLOODZONHpPN
License Law. ALTER construct the project(Sec.7014,Business and Professions Code:)'Dm—1-3PERMIT ISSUANCE
License Low does not apply m an ow ner of property who buil ds m improves thereon.and
wbommmctsfor such pmvacmr
jcctswiohacon (a)Iicenxenwn
A purauOuthe Conols ALTER-DRAW&VENT-WATER(HA) IEE SUMARY
❑ 1 am exempt under Sm, ,B&P C for this reuson BACK FLOW PROTECT.DEVICE SANITARY Y E N
Owner Date DRAINS-FLOORROOFR ,GOND RECEIPT#
WORKMAN COMPENSATION DECLARATION , . SCHOOLTAX YN
❑ I harebyaffirm that l have acertifi.srofcrosentaoself-i.ure,me artificateof - - RECEIPT#
Workeof Com FIXTURES-PER
pcnvtiminsurance or. copy Ncomf(Sec.7800,1ab C. which PARK FCC YN
coverndl actiloyp5ss� der thisa GAS-EA.SYSTEM .4 FTS RECFIPTM
Policy ISaJ s 6'r' I&CyIP 4'G BUILDING DIVISION FEES
Company L . GAS-EA. M VER4(EA) PLANCHECK FEE
El Certified copy,is heady famished.
❑ Certified copy is filed with the city inspection,division, G USTRL WASTE VIER
% GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' G SE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not becomplinedHNe permit is for a.hondaddollars(SIW) SEW R-SANITARY-STO F .200(?. MON FEE
or less.)
I cenifytbu in the performance of the walk for which this permit is issued.1091 WA HEA R /ELECTR
not employ any porton in my roamer so as to becomes subject to the Worker PAID
Compensation fawn of Cdifmnie. Due WAT R SY TIN Date Receipt#
Z Applicant
z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEWA—IDENTIAT PLMB. SQ.PT. TOTAL:
Fti became subject to the Worker's CArnpenvtim provisions of Ne Labor Code,you must
a > forthwith comply with such provisions or this permit shall be demand revoked. BUILDING FEE �•
GW. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that them is a construction lending agency for the performance of
U O the work for which this permit is issued(Sec.3097,Civ.C.) s TOTAL: ELECTRIC FEE
Oaf Lmdefs Name dh i if a, t6,
ti
H Lenders AddressT'Y ts- x ME ICAL,P •IIT IEEE r PLUMBING FEB
U 1 can fy that I have mail Nis application and state that the above mfonnaum r T" 4
>^ correct. legree mcrmtily with nil city and county oMinenas mtletete lawn relaungm PERMIT ISSUANCE MECHANICAL FEF:
building construction,and hereby authorize representatives ofthis city to enter upon the CONSTRUCTION TAX
U duwe-mentioned property for inspection purposes. ALTER OR ADD TO MUCH.
(We)ugreo m rove,indemnify and keep harmless the City of Cupertino against
limi lilies,judgments,casts and expenses which may in my way accrue against said City AIR HANDLING UNIT(TO VolCI'M)
in consequence of the granting of thin{ /�/
l I� I AIR HANDLING UNIT V I )
Signature ofAppLcem— /Contractnr� '�g— Bale EXHAUST HOOD(W
PAID
HAZARDOUS MATERIALS DISCLOSURE HEAT 'l1NIT(TO I MBTU) Data Receipt
Will the applicant.future building mcipano store or handle haamdous material HEATING UNIT(OVER 100,(M10 BTU) L
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(e)7
0Y. XNo VENTILATION FAN(SINGLU RESID)
Will theepplicant urfmure bvilJingacupam uxequipmemordeviceawhichemil
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
tsamo.dr contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100,000 BTU) p
#Dixti,t? 0y. w No 0`"
NEW RESIDENTIAL MECI I. SQ.FT. A%
1 have rtad the hamrdous.anima mJuircmenu under Chapter 6.95 of Ne
California Health&Safety Code,Sections 23505,25533 and 23534. 1 understand that
if Ne building dais not currently have a tanam,that it is my responsibility to notify the n
aeximum oldie a rcme I which mus be mu prior m issu ace of a Cmificate of yl Y L y y�/
Occupancy. _ . in V
Owner ser euthonsed en Date TOTAL: ISSUEDBY:
OFFICE