26413 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO sal"I'moll'liLRCTR PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL C ^ v
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION v 'i
BUILDING ADDDDRRE^S'S]I:�{/' R j SANTANYNO. TjPpLI(1VI]ONISUBMfl'l1'AL,CAI!
/ Vl OL" S,/ �/�/ ETM LOT# �L� 7
IL
OWNERS NAM' PHONE: CONTRACTOR'S NAM E:(AL LIC NO:
N/C CONTROL#
.•ARCHITLCT/ENGINEER: LIC NO: ADDRESS: 1 ❑
CONTACT: PHONE: .+'.-- *3i:a% f+ f-' ' - :'';BUILDING PERMIT lNFO
Lin
QTY��jw ELECTRIC PERMIT FEE
LVl6 � PERMIT ISSUANCE
ED ELfCf PLUMB MUCH
13
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
OKZ I herchyaffinn that l am licensed under provisionsofamIew9fcommcncing with TOB DES I ION
u100 Scainn9(IlhO of Uivisitn3nf the Business and Professions Code.end my license is io PANELS L
FFy-e tall torte and ercea 'j�
FZW I.icenx Clnas I.iiCT'SD-'yGz TnU UP T0200 AMPS
m6y Dme Cnnmmcmr 201-HIM AMPS
1 ,,Z ARCHITF,CI-S DEC SQ.IT.FLUOR ARBA 8/$U.Ir.
0 o5 1 understand my plans shall be used as public recon OVER 1000 AMPS
O% C
rrnl-w SIGNS ELECTRICAL
, Licensed Professional
o:ayye6 OWNER-BUILDER DECLARATION SPECIAL CIRCUTHMISC.
y Oe. I hereby affirm that I ata exempt from the Contractor's License law for the
3 M y following reason.(Section 703 1.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
F 4jOg which requires.permit,construct,cher.improve,demnlish,o,wtwi,any stmors
Eou prior to its issuance.also myuires the applicant for such permit to file a signed statement POWER DEVICES
AC 0 that he is licensed pursuant to the provisions of the Comrecwrs License Law(Chepmr SWIMMING POOL ELE C
t.ao� 9(commencing with Section 90(1pafClaim..3 of me Business and Professions Cade) VALUATION
toMot or that he is emmpuherefrom and the brsisfmme alleged exemption.Any violation of
1=7Q Senion 7031.5hyany applicanrm
t for.peit subjects the applicant to a civil penalty of OUTLETS-SWITCH -FIXTURES
E90 no more than five hundred dollars($5(10). NEW RFSIDENTI FEELER _SQ.FT.
��m ❑ I,usowdersdmepropeny,ormyemployees with wageamtheirsolecompeanation, STORIES 'TYPE CONST RUCTION
wi 11 do the work,and the structure is not intended(it offered for sale(Sec. Business
and Professions Cede:The Commences License law does not apply to an owner of
progeny who builds or improvesthemon,and who docs such work himself or through his
OCC.GROUP RES.UN TS
own employees,prongdotmprsuchent is s lel wiisire not elendalmoffered for sale.Ir,
however,
w.11 avec a orimpmvcm in issmt he within haild ofcomplve on.for mpsaw ofe osma. s TOTAL:
builder,will have the burden of proving m:n he did not build nr improve for purpose of
sale')' QTY. PLUMBING PERMIT FEE
❑ I,ae owneotprepro.Tod.Imures,and ontraaingwiCree)no
FOOD Nli pPN
keno t the project(Sea oro Nosiness and Professions Core)The Cem n.or's
whocolnwdoo notappjects oh acontpropcnywhosed puorimpmthe Coneod,aad PERMIT ISSUANCE
wicensewmsfor such prnjectswilhecantrucmr(s)licenxd pursuannothe Convenor's ALTER-DRAIN&VENT-WATER(G)_-- HTE$UMMARY
License Lew.
❑ 1 am exempt under Sm. ,B&P C for this reason BACK�LO J{s{� V OUT TUE IIS
YPl( SA ITARY Y N
Owner Dam s RpCFIPI'#
WORKMAN COMPENSATION DECLARATION DRAINS-Fl R,ROOF.A11 1RFA�CON . '� SC WE.TAX Y N
• ❑ IherchyalfrmthatlM1avea¢nifcnteofconseatmselbin,sure,oraceniticam°f FIX'I'U F.S- ,. 9RAP✓ L1/' RECEIPT#
Wurken'CumpensetionpQlmuMce orecenifiW cagy m<reof(Sec.Jgoo,LabCJ which sA FEE YN
covers all cmploY C�Yy � GAS-E .SYST[i Ol1TL RECEIPT#
vs I e BUILDING DIVISION FEES
Policy# l/1�s
Compo (b^�-/ -7 GAS-E TEM-OVERO(EA) ---- PLANCHECK FEE
❑ Cmifed ry is wby um shed.
❑ CenifiW copy is fled with the city inspection division. GRFASFJINDUSTRL WASTE I CEPTOR GRADING FEE
CL+RHFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not b<completed ifine permit is forone hundred dollars(SIM) SEWER-SANITARY-STRMEA.201t ENERGY FEE
or less)
I unify mmT Ne orm eo the woAfor whichmia ermitlsiJsued,luall WATER HEATER -. -LECTR
not employ nn non 1 y e t'wax to hetes e s n rkera' PAID
Compenxtio I ( dor WATER SYSTEM EATING Dam Receipt#
Z ,Z APPlicant
� NOTICE'I'OAI ICANT:I,nI m ig this Cenifcate of Eaemplon,you should NEW RESIDE IAL PLMB. SQ.FP. TOTAL:
rn become subjecuo a Works s Co pe sat on provisions of the labor Code.you must
forthwith comply with such is Permit shall be deemed revoked. BUILDING FEE QU
(� CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that therem a consvudinn lending agency for the performance of
V O the work far which this permit is issued(Sex.3097,Civ.C.) TOTAL ELECTRIC FEE
1--� Lender's Name
0 t" Under's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
-
V 1 terrify that I have read this application odd state that the above information is MECHANICAL.FEE
>" W correct. l agree to comply with all city and county ordinances and scam laws whaling m PERMIT ISSUANCE
F-' I, buihdingamsuuction,and hereby aumorim ne resema4ves ofthis city renter upon the CONSTRUCHONTAX
V Z above-memional property for inspection purpoao. ALTER OR ADD TO MECH.
(Wet a cut e ,indmmtify anA kap harmless the City of Cupertino against
liabildies,ju •m sandexp a hich may in ony way eccre against said City AIRHANDLINGUNI'I'('TO10,0110CFM)
in consalu ort ecus Ungaf is pe h.
01 AIR HANDLING UNIT(OVER IQOIXI CFM)
Signature, plica rhaa Dat EXHAUST HOOD(W/DUCD PAID
HA7ARD ATE IS DISCLOSURE HEATINGUNIT(TO 100.00l Date Receipt#
Will the a,hram Or room building occupant smre or handle hmarehor material
as defined by he Cupertino Municipal Cede,Chapter 9.12,and But Health and Safety HEATING UNIT'(OVER lo),000 BTU) TOTAL:
Cede,Section 25532(a)'f VENTILATION FAN(SINGLE RFSI
❑Yes ❑No
ISSUANCE DATE
Will rheapplicam or fumrebaddinguccupam useequipmem ordevices whichemiI BOILER-COMP(3HP OR IW, BTU) P A D
• b,worms air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER .GOO BTU)
Dislricl9
❑Ycs ❑No NEW RESIDENTI HGIL SQ.Br. `■{ NN 101994
1 have read the hNo
naaux materials requirements under Chapter 6.95 of the jum
Culifomiu Ilcuhh&Sufcly Calc,Scow,25505,25533 and 25534. I motes oo mm
ifthe building J«yyytrendy have ammed.dun it is my responsibility w notify me CITY Ur VUfrnII U
occupant of,pc quite me which must be met prim to issuance of a Certificate of _
aaap `(rhe 11 �11`y �� /.q `.
Owner wr or d iwngcnt Date TOTAL: ISSUED BY: V s / `� 1 -
OFFICE