26331/ APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO26331
BUMMIvT—EI.-If( RICA. PERMITNO
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUIDINGPROJP:CT IDENl IF'ICAI']ON
BUILDING
/ADDRESS: `1, SANITARY NO. APPLICATION SUBMITTAL DATI!
�K s UNIT# LOT0
OW 'RS NAM[f PHONE: CONTRACTOR' NAME: eI.I�NO: ��
/LV•Y- «' L !_ A&tj� cif. N/c cormcol,a
1A NCHITECTIENGINEER: LIC NO: ADDRESS:
Z _ '061?5 Ra
'ONI'ACT:C,r G - u ' -✓ PHONE: a +� �", 'BUILDING PERMIT INFO
z27-"L�OD QTY S q�ELF.CTRIC PERMIT.'c FEE
vd '� T• 'Z"'°k L - B ELECT PLUMB MECII
PERMIT ISSUANCE El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
LOB DESCRIYI'ION
❑C 7 1 hereby affirm dal I am licensed underpmf
visionsoChapter9 FomNmencingwi
4]00 Section 7000)of Division 3ofthc Basineaund Professions Code.and my license is in PANELS ` , sk
Fran from and effect.
UPTO2
F-ZW License Class—Lie,#_
WAMPS
`�--/
y?y Doe Contractor 201-1000 AMPS SQ.Flt FLOOR AREA E/Sp.LST.
F iso'/_ ARCHITECTS DECLARATION OVER 1000 AMPS
zOm— I undeori rd my plans shall be used as public records.
PyFW
SIGNS ELECTRICAL
Qj 17
Licensed Professional
�ItlmQ OWNER-BUILDER DECLARATION SPECIAL CIRCUR/MISC.
KW U 1 hereby offirm that)an exempt from the Contractors License Law for the
OW "so following reason.(Section 9031.5.Business said Proresslons Cei Any city or county TEMP.METER OR POLE INST,
m0; which requires n permit an construct,alter,improve,demolish,or repair any savaam
T5 to its issuance,also ru Neu licu^t for such uo file a signedsmlement POWER DEVICES
�a poor ret to pp pract
Q
Nal Im is licensed pursuant m the provisions of the Contractor's License Law(Chapter VALUATION
a'yo� 9(emnmencing with Section 7")of lTvisionJofthe Business and Professions Cade) SWIMMING POOL ELECTRIC
or No he is exempt therefrom and Nc basis for the alleged exemption.Any violation of ryp
�zQ Sat ion 7031.5 by anyapplient for a Permit subjects the applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES /���•
not more than Eve hundred dollars(S500). NEWRESIDENTIALELEC'M _S FT.
=E:0 [I I.asowncroflhe pmpeny,ormycmploycerwith wages as Neirsolernmpemauon, pp�I 11g STORIES I1 CONSTRUCI"ION
pW,3_o will do the work,and the structure isnot intendedoroffemd frrmle(Scc.7044,Business '1'Y Ii
V �- I'�. I•, p p II
and Professions Code:'1'he Contractors License Law does not apply to on owner of t�
property whomildsor improves thercon.and windiest such work hinestfor through his
cmpoYcs,provi Prov � / OCCG P � RES.UNITS
1 e dadmpr veli it enwithin not dedorofraw the
own r- ,� .il II
however,lhe huilJingor improvement is sold within one year of completion,the owner-
builder will have the burden of proving Net he did not build or improve lar purpose of
aero.). QTY. PLUMBING PERMIT wmllz FL ) .oN: APN
❑ [,as owner j th(Sce.property,am exclusively contractingofirofits Coth dce^sed Carburomo m,
ortmct w project(Sec.7044,Business and Pmofessimu Camp the Comracrrs
License law Joel not apply to mmwnernlproPcny who huilJs arimpraves therms,end PERMIT ISSUANCE
whocommcts forsuch projects with a comractons)licensed pursuanuo lbC Contractor's ALTER-DRAIN&VENT-WATER(EA) - FEE SUMMARY
License Is..
❑ I.,it eaempl under See. ,B&P C for Nis mason BACK FLOW PROTECT.DEVICE U'1' IDI:FEES
SANITARY YN
Owner Dat° DRAINSFLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
I1,meby affirm that l have a certificate of consent to self-inure,or a certificate of FIXTURES-PER TRAP RECEIPT#'
4mkers'Cnmpensminn ln.vumnceor oeenifiW wPy thereo[(Sea J#W,WDC.)whicM1 PARK PER Y N
covem all employees under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy at BUILDING DIVISION FEES
Company GAS-EA.SYSTEM OVER 4(EA) PLANCHECK FEE
❑ Cedified copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASMNDUSTRL WAS'T'E INTERCEPTOR GRADING FEE
CERTIFICATEOF EXF:MPLION FROM WORKERS' GREASE MAP SOILS FEE
COMPENSATION INSURANCE
This section need not be comlrleted ifthe permit is far one hundreddollars($100) SEWER-SANITARY-STORM EA.201 ENERGY FEE
or less.)
I ccnify but in he performance of the work for which this pe—it is issue.I shell WATER HEATER W/VENT/ELECIR
not employ any person in any assumes so as to become subject to the Workers PAID
Coni'msation Lawlor Culifomia. Dam WATER SYSTEM(TREATING Date Receipt#
Q z t NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
Z Z NOTICENUTIGIi TO APPLICANT:if,alien making this Certificate of Exemption,you should
ftvirme m the Workers Compensation provisions of the labor Code,you must BUILDING FRE
p > fowith comply with such Provisions or Noed
is permit shall be dmrevoked.
Gq
LEI
Q CONSTRUCTION LENDING AGENCY SEISMIC ME
Z
1 hemhy off ren Nat Nem is a constmction lending agency for the performance of
TOTAL: IH.ECTRIC FEEU O the work for which this permit is issued(Sec.3197,Civ.CJ
Lenders N. PLUMBING ttili
I
P- IgndAddress QTY. MECHANICAL PERMIT FEE
tU terrify that I have mad this ity and iou and site Net the above information is MECHANICAL PEE
i- building lagreemon,comply
and with all ytatyamd countyordinancesOsmtd statelaws
ntr upon the PERMIT ISSUANCE
f-' building construction,and hereby outhnve representatives of this city menmr upon CONSTRUCTION TAX
U z above-mentioned propcny for inspection purposes. ALTER OR ADD TO MECII.
agmc to save,indemnify and keep hmmle.Ne City of Cupertino against
liaibi f ,.,judgment.costs and expenses fch may y wayaccrue against said City AIR HANDLING ON IT(10 I RW CFM)
in quince of the gramin this it.
AIR HANDLING UNIT(OVER 10.000 CFM)
'igmbq o Ap no in
ate EXHAUST HOOD(W/DUCTI
PAID
IIAZARUOUS MATeR1A1S DISCLOSURE HEATING UNII'(TO 100,01X1 BTU) Doe RecciPl#
ill the applicant or future building occupant store or handle hazardm1 material HEATING UNIT(OVER 100,1100 BTU) L
as retired by the Copenim Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(a)7 VENIULATION FAN(SINGLE RISID) SM
❑Yes ❑No
ISSUANCE DATE
Will be,a licamorfulure buildin cu tuse ent ordevices whichemil BOILER-COMP(3HPOR IW,000BTU)
PP Bb pun Area A p p
Sv.¢minrs air contaminants as Jefincd by the Bay Area Mr Quality Menegernem BOILCR-COMP(OVER IW,000 BTU) I(' W 1 D
❑Yes ❑No m NI:W RESIDENTIAL MECH. SQ.FT.
I have mad the hazvdous rtumeials mr domorms order Chapin 6.95 of the Mky — 2 1994 .
Culifomia I leallh&Safety Code,Sections 25505,25533 and 25574. 1 understand that
if the building does not currently have a tenant,that it is my responsibility to notify the g51
occupant of the requirements which must be met prior to issuance of a Certificate of C�'(Y uIii i tit I�u/Iv�U� T/
Occupancy.
0wor,
owner ae wntad..ed#gen, roe IroTAL: Issuyo BY:
OFFICE