26359 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HU ITECTRI PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL LJ
s BUII.DIN(2 PROJECT IDENTIFICATION
BE( TF.
DING ADDRESS: �n pp SANITARY NO. APPLICATIONSUBMITTALDA
(/.DING
OS /gi�ILL,C,dQa AVE, , JUNoG LOT#
O ERSNAME: 2CONTRACTOR EAT 514ZGETC SC/kIW- P O CONACTOR'S NAME: ��p LIC NO:
/RST BAPTIST LNNRG 4Q YYl� PAUL IC/M IC/MN& CON TROL#
. ARCHITECT/ENGINEF.R: ' LIC NO: AUU 5: - ❑
CONTACT: PHONE: . ti* "' "'" BUILDING PERMIT INFO
f y ELECTRIC PERMIT^�` FEE
�oSEPN L�pAG� �CY 4YG 33t,F/ PERMIT BLDG ECT PLUMB MECH
❑ ❑
LICENSEDCONI'RACTOR'SDECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
y.Z Iherebyaffirm Nations littnxdundmpmvisions ofChapter9(cormtmencingwith
gE Section force it of Division t of Ute Bulinus and Profuuons Code,end my littnx is in PANELS
y� lull us.Clad effect.
a I.iccnse Close Lic.# WT0200 AMPS '
r4F,.<6 Date Conttxmr 201-It100 AMPS
Z8vs ARCHITECTS DECLARATION OVER IWO AMPS SQ.FT.FLOOR AREA $/SQ.PT.
I understand my plans shall be used as public records. �
�OZ— SIGNS ELECTRICAL IIS.
��d Licensed Professional _ d—\ L E D S N
4y�stY0,6 OWNER-BUILDER DECLARATION SPECIALCIRCUITMBSC. )) p p �,-'• (� T�
LU3LL V I hereby affirm that 1 em exempt from the Convectors License Law for the A'� 17�
billowing reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST. VVVV va..✓ E gg ii
which requires a permit to consumer,alter,improve.demolish,or repur any suunure
}� priori its issmnce,uso requires lheepplicant for such permit ra flleasigned satement POWER DEVICES DATE 4141
Ill 4O that he is licensed pursuant to the provisions of the Ci n onim's License Lew(Chapter
p• p5 9(commencing with Section 7000)of Division 3 of Ne Business and Professions Cade) SWIMMING POOL ELECURI — VALUATION
y�_y or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWRCHES- RE
< Section 7031.5 by any applicator for a permit subjects the applicant w a civil Penalty of
G not more than five hundred dollars($500). NEW RESIDENTIAL ELECfR
I. ❑ I,asowncro❑hep op ty,ormyemployttswithwegeautheirealecompnsation, TORIES TYPECONSTRUCTION
c, will do the work,and the structure isnmintendedoroffmed for xle(Sac.704,Business
and Professions Code:The Counswun s License Lew does oar apply to on owner of
property wholauldsorimproves thereon,and whodoessuch work himselforrhmugh his
own employees,providedthar such improvementsmonm intudedorofferedforsale.If OCC—GROUP RES.UNITS
however,Ne building or improvement is sold within of build or improve for nge owner- TOTAL:
builder will have the burdrn of proving that he did not build or improve for purpose of
Ie.),
❑ I,as uwnerof the property,am exclusively convening with licensed contractors to QTY. PLUMBING PERMIT PEE FLOOD ZONE "Nwec
umsct the project(S .7044,Business and Professions Code:)The Contrxrars PERMIT ISSUANCE
License Law does not apply to an owner ofmcdoemy who builds m improves thereon,and
who contracts for suchprojectswing.conuectmrs)licenm sed pursuing the Contractors ALTER (FA)
License Lew. FEE SUMMARY
❑ 1 mn exempt under Sm. ,B&P C for this rcnsan1 ES
HACK FLOW PROTECT.DEVICE SANITARY Y_N
Owner Date RECEIPT,
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA.COND. SCHOOLTAX Y N_
❑ lhereby affirm that l have a certificate ofconsent to xlf.inaurc,in a certificate of RECEIP #
Workets'Compensation lnsumnce ora certified copy thercof(Sec.38011,LmCJ which FIXTURES-PER TRAP PARK FEE Y_N
covers ill employee's under this permit, GAS-EA.SYSTEM-1 INC. OUTLETS RECEIPT#
Policy If BUILDING DIVISION Ff
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
EI Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASEBNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This sectionneedna be completed ifthe permit is for..hundred dollars(SIM) SEWER-SANITARY-STORM EA.200FT, ENERGY PEE
or It
I certify that in the performance ofthe work for which this permit is issued,l shell WATER HEATER WIVENT/F.LECTR
not employ any person in any manner iso as to become subject to the Workem' PAID
Compensation Lawaof Celifomia. Dan WATER SYSTP.M/1RFATING Date Receipt#
Z Applicant
NOTICE TO APPLICANT:If,mus,making this Cenificme of Exemption.you should NEW RESIDENTIAL PLMIL SQ.ff. TOTAL:
become subject to the Workers Compensation provisions of the Labor Cade,you must
�i > forthwith comply with such provisions Or this perdt shin W deemed revoked. BUILDING IEE
a [� CONSTRUCTION LENDING AGENCY SEISMIC FEE `
VZhereby affirn that there is a consuudtion lending agency For the performance of
O the work for which this permit is issued(Sm.3097,Civ.C.) TOTAL: ELECTRIC FEE
Lenders Name PLUMBING FEE
u" ~F Centime ify the QTY'a.?, M,ECHANICAIf PER'MI'T ( PEE;
V 1 candy that 1 haps read this application and stem that the above informations tO E ' ' MECHANICAL FEE
cartes Iegree to comply with uldryeM cauntyoNinenceauM stem laws relating to PERMIT ISSUANCE.
buddiagconstracron,and hereby anthorire reprtsenutivesmfthisciry to enter upon the
U 7 above-mentioned property fnr inspection purpuses. ALTER OR ADD TO MECH, CONSTRUCTION TAX
G (We)agree to save,indemnify and keep hwmlass the City of Cupertino against
liebilitics,judgments,costs mW expenses which may in any way giants against said City ATR HANDLING UNIT CFO I U."CFM)
cnnseque of the grani of thio pe i AIR HANDLING UNIT(OVER 10,001)CFM)
plicen EXHAUST HOOD PAID
H ZARDOUS MATERIALS S LOSURE HEATING UNIT TO 100,000 BTU) Dare Receipt#
"a applicant ort fuwrc building«cu tat orharWlelururdousmsmdu HEATING UNIT IW,"B
m defined by the Cupertino Municipal Code, p 9.12,and the l lealth and Sahty BTU)
Code,Section 255320)7 VENTILATION FAN(SING
1.E RIiSID)
11 Yes ❑No
Will theapplic'm!mfutumbuildingmcupont uucquipmentmdeviceswhlchemit
BOILER-COMP IMP OR 100,0110 BTU) I$$UANe°E DA
hazardous air nomunams as defined by the Boy Are Air Quality Management iBOILER-COMP(OVER 100,000 BTU) MAY 16
Disrrict7 1994
❑Yes ❑No NEW RI'SIDENfIAI.MECH. SQ.FT. 1Ay
1 have read the homWous nationals requirements under Chapter 6.95 of the C�IY airVurLnI
Cui1'omia Health&Safety Cade,Sections 25505,25533 and 25534. 1 undersand Nat IIg V
if the building drys not currently have a tensm,that it is my res amtsibiliry to notify the
occupant of the requirements which must be mer prim to issuance of a Ccnificam of
Occupancy.
Owner or emhoriuJ ager, Data TOTAL: ISSUED BY: