26158 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINI II.tudonih'1,F14R[CAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
26,158 BM 1LDO
BUILDING ADDRESS: UNGPROJECIIUENTIFICA'I'[ON
SANITARY NO. ARLCc)AIION$(IU('BMHI'AL DATE
-75a/ Gra •t- /RJo}J// OIN I'D r UNIT#' LOT# V
OWNERS NAME: PHONE: CONTRALTO ' NAME: LIC NO: N/C TROL#
1. Mari#ok blew as -foxes CEio C360 60 1,S
ARCHITECI'/ENGINFER: LIC NO: AUWtE'SS:CJ� /I r.�.OWOsy( LyL ST
CONTACT: PHONE. QTY. V 1, ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PL B MELD
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACT'OR:S DECLARATION APPLIANCES-RESID17N'RAL IOH DIiS R1Pf1 N
Oa'Z I hereby affirm that l am licensed under foovismnsofchapter9(commencing with G #+WJ`G
WOO S«timr100dlof Divi1ma3ofths Pu i essand Professions Cade andmylicenuism PANELS
WF. fullfirame adeffem. Q's�{� ��'k�
<,, LicenseCla.ss CLm. 600 " 11PT02f0AMPS �pa'✓ W 4v a,
hQz Uate Costa OVER
AN / I'R.
I—yZ ARCHITECTS DECLARATION F OOR N' S/SQ.FT.
zc` I understand my plans shall used as public records. OVER 1000 AMPS ,
F rgFW SIGNS ELECTRICAL. tl
Z Y j Licensed Professional
ee6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
OW, I hereby affirm that I am exempt from the Contractor's License Law for the / W
W3 Wy following reasorl(Section 7031.5.Business and Professions Code:Any city in county TEMP.METER OR PULE INST. (O
I,a O Q which rcyvie a pemtit to construct,titer,improve,demolish,or repair any structure
KWQ� prior to its issuance,also requires the applicant forsuch Permit o file a signed statement POWER DEVICES _
wtyp0. that be is licensed puaumn to the provisions nflhc Cmumetor's License Law(Chapter VALUATION
L i1o�' 9Rommencing with Section of Division J oftbo Business and Professions Code) SWIMMING POOL ELECT RIC
m-m orthat he is exempttherefrom and the bssisf«the allege4 exemption.Any violation of /S_O C
Y Section applicant t the altyof OUTLETS-SWITCHES FI%TLRES '
F Z Q Y a^Y hundred
icon subjects pen
EZC n 1,arcc)anfiofthepreddallars(5518)' NEWRESIDENIUALELECIR _SO FT. STORIES TYPE CONSTRUCTION
��a2 ❑ Lusowrk,anahcpropcny,ormyempended raffmcgcsasthei(Sm.conmensiness t
a 3— will do Professions
wons C d e: sprocture The Cma not intended se La does not apply to an,owner
of
and Professions CWe:The Cnmanors license Lew does not apply m an owner of
pmpeny who builds or improves thereon,and who d«s such work himself or tM1rough his
employees,provided Nd such improvements are not in¢ndN ondfercJ hnsale.IL OCC GROUP RES.UNITS
however,the buildingor improvement is sold within one yearofcnmpletion,tbeowner- TOTAL:
builder will have the burden of proving that he did not build or improve fm puryas,of
sled' QTY. PLUMPING PERMIT FEE FLOOD ZONE APN
❑ has nwnerofthe propertY.am exdusivelycontracting with licensed contractors to
onstrud the project(Sm.1044,Business and Professions Code:)The Contactors
License Law does not apply to an owner of property who builds or improves thereon,and PERMIT ISSUANCE
wbocontrans for.vueh projects with a contactuds)licensed pursuant to the Contractor's ALI'BR-DRAIN&VENT-WATER BEA) FEE SUMMARY --
License Law.
❑ I ern exempt under Sec. .B&P C for this reason OMSIDEFEJS
BACK FLOW PROTECT.DEVICE SANITARY YN
Owner Date DRAINS-FLOOR,ROOF.AREA,COND. RECEIPT'#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
I hereby affirm that l have a cenifcate ofconwnuo self-insure,or attnificareof ITVfURFS-PER TRAP RECEIPT
o mCompensation lnmrancem.cenified copythermf(Sm.3800.Lab C.)which PARK FEE Y N
RECEIM#
onsets all employee's under this peonit, — GAS-EA.SYSTEM-]INC.4 OUTLETS BUILDING DIVISION FEES
Policy If l 7
Company mss GAS-U.SYSTEM-OVER 4(U) PLANCHECK ME
❑ Certified copyk hereby furnishe s
CenilicJ copy it fled with the city in.vpection division. GRUSEPNDUS'FRI.WASTE INTERCEPT OR GRADING LET
CER'T'IFICATE OF EXEMPTION FROM WORKERS' GRUSF,TRAP SOILS IFF.
COMPENSATION INSURANCE '
(FIdswodan need not hernmplcted if the permit is Airline hundred dollars IS 1 W) SEWER-SANITARY.STORM EA.200P1. ENERGY FEE
0r less.)
I certify that in the performance of the work for which this permit is issued.I shall WATER HEATER W/VPNT/F,LECIR
not employ any person lin any manner so as to become subject to the Workers - PAID
Compensation Lawsof Calim ua. Date WAl'ER SYSTEM/TREATING Dam Receipt#
z Applicant
Z� 0
NOTICE 10 APPLICANT:If,after andualthis Cenifimre of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
L' p] becomexubjecno the Workers Compensation provisions of the Labor Came,you most
7 fonhwith comply with such provisions or this permit shall be dm
eeed revoked. BUILDING FEE
W [� CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1 hereby affirm that there is a construction lending agency for the performince of
U O the work for which this permit is issued(Sec.3091,Civ.CJ TOTALELECTRIC FEE:
Lenders Name PLUMBING FEE
0 F Lender:Address QTY. MECHANICAL PERMIT FEE
U I ecnify that 1 buvc rend this application and state that the above information is MECHANICAL FEE carat. I agree to comply with all city and county ordinances and sate lows relating to PERMIT ISSUANCE
F" N builiingcomtructimand hemby sutM1orimmpoescnativesofthis city to enter upon the CONSTRUCI'IONTAX
V Z aMve-mentioned property for inspection purposes. ALTERORADDTOMF,CH,
(We)ugrcc a save,indemnify and keep harminw the City of Cupertino against
Iiabilities,judgmetns,costs ondexpeases which may in any way mcoe against said City AIR HANDLING UNI'1'('1010,0(10 CFM)
in coalescence of the gaming of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signamreof APplicanUContranor Date EXI IAUST HOOD(WMUCq PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant m furore Iml,intirmcupant xlure or handle hazardous matenal TOT
as defined by the CupeNno Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU)
Cade,Section 2553200,
C1 Yes ❑ No VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
Will theapplandmorfuambuilding«cupant useequipmem«devices which emit BOILER-COMP(311P OR 100,000 BTU) p
hazvp Mdous ab contaminants as defined by die Bay Arm Air'Quality Management BOILER 100.000 BTU) f ' D
®District?
❑Vcv ❑No NEW RESIUENTIAI.MI3C11. SQ.1°I'.
I have mad the hazardous materials rcyairements under Chapter 6.95 of the MAY 25 1994
California Ileahh&Safety Code,Sections 25505.25533 and 25534. 1 understand that
if the building does not currently have a tenant,dal it is my reslxmsibility to notify the /s L
«cup'J' f tM1e requirements which must hand prior to issuance of eQjCcnifi ¢of C1 QI VU/s I1111V1�
Owner«authuriacJ agent Date TOTAL: ISSUED
OFFICE