26847 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
F77777 -'IIUII.DINGPROJFA;I'IIIENf1PICA'1'ION 26847
BUILDING ADDRESS: SANITARY NO. APPLICAT10NSUBMITTALDATE
33Y &z& X8� p LOT#
WO SNAM.: PHONE.: CO CT R' AME: LICN //111 V �-
OO AI �// 9 N/C CONTROL p
pE
•A CIRIECIIENGINEER: LIC NO: A V l�C� ❑. ^
AD r et. f/�//r/0 /�C
CONTACT: RI,PBRMI j FEP 'us'- r x-sBUCLDIN6 PERMIT INFO
BO FLEl FU
El
PERMIT ISSUANCE Yh�y(I
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL .)OBD ION
OCZ Ih700EofDi lhaH anlicensedunderprovisionofCTaptm9(cammrncingwith �.�/]/ � i�.�r
Y100 Sermon]000)of Di vision 3 ofthe Business and Profession Code,and my license is in' ppNElg �Cej>://(.. lkk&� ! K/
&'d full force and effect. J
.<0� Licease
e_e Lic.N� UPT0200AMP5 /-
yQy Data Cnntmcmr / 201.1000 AMPS
Z O y'Z ARCHITECT'S DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
OZ-0 l undersand my plans shall h used as public records. 2,9F:k SIGNS ELECTRICAL
6s
LicensedPofe tonal
OWNER-BUILDERptfrom Ce CmareON SPECIAL CIRCUIT/MISC.
Xa hereby alfa that 1 a exempt the Camrtmare License Lew fm the
Itl3Orn following reason.(Section]031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
�y'I which requires o permit m concoct,alter,improve,demolish,or repair any swctme
>-� priorto its issuance0lao requires theapplicam forsuch permit to III easignedsatement POWER DEVICES
��OOm that he is licensed Pusa sot m the provision.(Ne Convanors Limum Law(Ch n. -
c, eLL 9(commencing with Seetion]000)of Division 3 ofthe Businasaand Profession Code) SWIMMING POOL ELECTRIC VALUATION
y❑y
or that 13151, Ohercfromand the hmmfor the alleged ealicant n.Any ivil Peetion of OUTLETS SWRCHES-Fl%TURES
a Sedion]03LS by nny dieddollfor 4500mit subjeca the epplicnmroacivil penalty of
O not ml,nown rorhundred M,or (5cmpl NEW RESIDENTIAL'ELECfR _SQ.Fr. STORIES TYPECONSTRUCTIO
❑ Laawork,aDheproperty,ormyempinyed.Odwege filerl cussicnme compensation, _
will dolhewmk,ends: he Cortmears.License of.does am apply hoan..a,ofs. - 8
end Rofcsxions Cods:The Contmctore License 4w does not apply b an owner of
property whobuiWsmimproves Ncrton,andwhodma such woh himulfmtluvugh his
witemployces,progorri Nm svchim is sold m nare,eandedmoffercd thcarw.TL .00C.�R RES.UNITS
haweer ,will avec a burden
of provin issoldhe id noneyea or improve
omm,fee purpose f TOTAL
builder will have the burden of proving that he did not buil)or improve fm purpose of
ante.).
ElLss owner oftbe property,amexclusively connecting with licensedcontracmrs to QTYT, PLUMBING PERMIT PRAT FL �PN
construct the project(Sec.]044,Business and Professions Code:)The Contracture PERMIT ISSUANCE PDATE
License law does not epplytoan ownerof praperry whohuilJsmimprovesthaean,end
wh000mmces fa such projects with accountants)licensed pursusnttothe Conusstora ALTER (PA)
License Law. FEE SUMMARY
❑ I eras exempt under Sec. ,B&P C for this reason ST E
RACK PLOW PROTECT.DEVICE SANITARY Y N
Owner - Dem DRAINS-FLOOR,ROOF,AREA.COND. RECEIPT.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
T hereby effinn thetlhaveecenificate of conumto¢If-inmrt.ora certifirnte of FIXTURES-PER TRAP RECEIPT is
W kers'Compensation Insurance or a mrdificd copy thereof(Sm.38)0.Lab C.)which t 71 PARK FEE Y—N
—
covers all employees under this permit. GAS-EA.SYS1EM-1 INC.4 OUTLETS RECEIPT N
Policy N BUILDING DIVISION PEES
pang an U T GAS-CA.SYSTEM-OVER 4(EA) PLANCHECK FEE
Crol Bed copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASPIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thosection need notbe completed ifthepemdt is forms,hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I tardily that in the performance of the work for which this permit is issued,I shall WATER HEATER W/VENTdiLECfR
not employ any person in any manner so a to becoma subject to the Workers PAID
Z CAcplpantion Lawsof California. Date WATER SYSTEM/TREATING Data Receiptp
icant
22 NOTICETO APPLICANT.If,after making this Cnnficme of Esemption,you should NEW RESIDENTIAL PLMB. SQ,IHL TOTAL:
U) become subject to the Workers Compensation provision of the Labor Cade,you must
a , forthwith comply with such provision orthis permit shall be deemed revoked. BUILDING FF.F, r
Z CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby uffirm that there is a concoctng agency for the performance of
V the work for which this permit is issued(Sec.309],Civ.C.) TOT ELECTRIC FEE
O Lenders Name
0 LL. Lenders Address QTY if�fECHANIQALPGRMITt. FEE - PLUMBING FEE
I certify Nat 1 have mal this application and nate that the above information is
UJ correct.I agree to comply withal)city and county ordinances and sum laws miming to PERMIT ISSUANCE MECHANICAL HE
-' CA building construction,and hereby auNorize,represenativesofthis city to enter upon the
V 7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECIL CONSTRUCTION TAX
G (We)agree to save,indemnify and kap harmless the City of Cupertino against
Iiabilities,judgmena,cosls and espenseswhichmey many way accmeagainst said City AIR HANDLING UNIT QO 10,"CFM) .s'
in cotaminartt of the gmnfing of this permit. AIR HANDLING UNIT(OVER 10,000 CFM)
Si,rmuroof Applican4Contmcmr Dna E%IIAUSTHOOD(W/DUC1)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Receipt#
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100.00p RTU) TOTAL
ax defined by me Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cade,Section M532(a)T VENTILATION FAN(SINGLE RPSIO)
13 Yes No 40
ISSUANCE
licanmrfmure buildin meta BOILER-COMP(3HP OR 1(q,000 BTU) 40'�®NCE DATE
pp g pe muse equipmentQualit Management JD
hazardous air contaminants as defined by the Bey Arca Air Quality Management BOILER-COMP(OVER 1110,000 BTU) a 4i'
• Distinct? - U�; `
❑Yes Ff NO NEW RPSIDIN'1'IAL MECII. gQ,PT. �s V(a 8 ,Q
I have mad the hazardous materials requirements under Chapter 6.95 of the Cp r(� 1994
Cnlifomie Health&Safety Code,Sections 25505.25533 and 25534.1 understand that (e`/„C
if the building does not currently have a tenant.do, I is my razor, I try to notify the �IINO
`bwaapaqt of the requirements which must he et or m issu c f e Cenificme of
Occupy C�
O eroreu orizWagem f Data TOTAL: ISSUED BY:
OFFICE