26996 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOII I�IAINT.-I11.111R CAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL, 26996 C (�C
BUILDING DIVISION BUILDING PROJECT IDENTwICA'1'ION' G U J V
BUILDING ADDRESS: / SANITARY NO. APPLICATION.URMITIAL DATE
3 LD c UNIT» I LOT'»
11.
WNIRS NA ' PNONE: CONTRACTOR'SNAMF,: LIC NO:
G � � Q J ..r F of N/C ( N ROI.
RCI ITECITAING EBB: LIC NO: ADDRESS: rL G /YJ/ASO ✓i EJ
CONTACT: PHONE: 673 O BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEF,
BLDG ELECTMECfi
PERMIT ISSUANCE 11 11LUMR1:1
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB ES RI IO
QO:z 02 Ihereby 7W)affmvision that I 3 oftensedinss and Professions
Codir9nd mmecense with
FO{O{.. fulltf�rce000i1)of cHDivisianJofthe Business and Professions Cade,eM/m�y license is in PANELS
�U[� �' (� UPT02MAMPS
<z- Liccnsc Class Lic,p f n
h=y Date Commctor TGIF 301-LIMP AMPS SQ,IT.FLOOR AREA $/SQ.FT.
ZOvI? ARCHITECT'S DECLARATION OVER 1000 AMPS
O Z—❑ I understand my plans shall be used as Public rax nis.
F 4 L W SIGNS ELECTRICAL.
Lic.owd Prafexvional
Kra< OWNER-BUILDER DECLARATION SPECIAL CIRCUEDMISC.
KC , I hereby affirm that I ore exempt from the Catamaran's License Law for the
WafF followingreason.(Section 7031.5,Bminessond Professions Cade:Any citymcuunty TEMP.METER OR POLE INST.
which"arms a permit o c andira ,offer,improve,demolish,or.,in any dractore
�nLLLL!11}� prior In its issuance,also requiem NPermit e applicant for such peit to fife a signed statement POWER DEVICES
fee prior
aa�Wthat he is licemed pursuantIn the provisions of the Contractor's License Law(Chapter
9(commencing with Section 7000)of Division 3 offhe Business and Professions Code) SWIMMING POOL ELECTRICVALUA'T'ION
or that he is exempt themfrom and the basis for the alleged t An violation f
�rsy p he pion.Any pen ono OUTLETS-SWITCHES-FIXTURES
p.Z Q Section 7031.5 by any applicant for a pcnnil subjects the applicant m a civil penalty of
of more than five hundred dullars(S5001. NEW RESIDENTIAL.ELECRt SO.IT.
Ct. ❑ 1,mowneroftheprol rty,ormyempl yeeswithwagesmtheirsolccompensation, Sl'ORIF_S TYPE CONSTRUCTION
y3_ will Jo the work,and the struclumis not intended moffcrcd forsafe(Sec.7044.Business
and professions Code:The Comma mer License Law does not triply to an owner of
propeny whnhuildsor improves thereomand whodoessuch work himselforthrough his
own employerrc
s,providedthat such impovementsanot intendedomffated forsole.If. \\ `OC .GROUP RES.UNI'T'S
however.the buildingm improvement is sold within one year ofcompletion.the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of C )
sale')' QTY. PLUMBING PERMIT FEE 1AFLOOD ZONE�, APN
ElI,asownerofthepmpeny,amexclusivelyconwctingwiNlicensedc..mom ty
construct the project(Sec.7144,Business and Prefnsians Code:)The Cunmaors pEl2Ml'1'IDRSSUANCE
m
License law docs not apply than owner of property who builds or improves thereon.and
who<oniis forsuch projects wiihacontractor(s)licensed punuanuo the Contractors
ALTER- AIN&VENT AWA (FA) FEE SUMMARY
License Luw.
❑ I am exempl under Sec. .B&P C for this reaun BACK ROW PROTECT.DEVICE UT:IDIi FEES
SANITARY YN
Ow°errDate DRAINS-FLOOR,ROOF,AREA,COND. 'SAL RECF.IPI'p
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ etsCyaffrm thatlhovaem.ccamofc.,IncomfEfesure,o.aanifatenf FIXTURES-PER TRAP �— RF:CEIPI'p
evvents'Compensationlnruruoaoracenifcd copYthcrwQSec.3gU11,Lab CJ which PARK[EE Y N
n tall empin ee's under this permit. ECEIPT a
Policy
Y GAS INC.INC40tITL[TS �_ BUILDING DIVISION FEES
Comp N
Company GAS-F.A.SYSTEM-OVER 4(CA) PLANCHECK IEE
❑ CenlBed copy is hereby famished.
❑ CeniOul copy is filed
with the city inspection division. GREASPjINDUS77L WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS IEE
COMPENSATION INSURANCE
(Thisuction need not be compinrd if Ne paretic is Tanana hmndreJ dollen(SI00) SEWER-SANITARY-STORM G.2IM1I9'. ENERGY 1`617
on less.)
I cerci fy that in the petharanae,of the work for which this permit is issued,l shall WATER HEATER W/VFNT/ELECIt
not employ any person in any manner so m m become subject la the Workers' PAID
Compeneationlawsof California. Date WATER SYSTEMRRGTING Date Receipla
Z Applicant
z � NOT ICE TOAPPLICANT:If.after ducking this CertlfiamofExemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
r become subject to the Worker's Compensation Provisions of the Labor Code,you must
C� > froloah comply wi it,such provisionsor thislxnnit shall be deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby ifftrm that here is a construction lending agency for the Performance of
V O the work for which this permit is issuW(Sec.3097.Civ.C.) ELECTRIC FEE
Lender's Name PLUMBING FEE
0 F Leaders Address QTY, MECHANICAL PERMIT FEE
(..) I cmify that I have fad this application and stem that the above informed.it MECHANICAL FEE
L1-) nmecl.lagme In nnnpty with all cityand county rafinancestnd stat lswsrelmingto PERMIT ISSUANCE
ungconstmctinn.rend hereby authnriu reprcsenrtives of this ciry laenterupanlhe CONS'1'RUCI'ION TAX
V z above-mne
entiod progeny for inspection purposes. ALTER O0.ADD TO MECIL
(Wc)agree to inJcmmfy and keep harmless tM1e City of Cupertino xgainn
Ilebiloics'u ems, errand expert. awhichmayint ywayacc against wid City AIR I]ANGLING ON I P(TO IB,(MMI CFM)
in rs cc off gnarling of this it.
/ AIR HANDLING UNIT(OVER I B"CFM)
S mat App cudusctmrwmr Date EXHAUSTHOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam Receipt a
Will the appfiaat orfoma building occupantsmre or handle harardouatvtedal HEATING UNIT(OVER 100,1100 PTU) TOTAL
as defmwd by the Caper ino Municipal Cale,Chapter 9.12,and the Hwhh and Salny
Cade,Section 2553200? VENTILATION FAN(SINGLE RESID)
❑Yes ❑No ISSUANCE DATE
Will the appliantor future buildingercupant ouequipmentordeviaswhichemit BOILER-COMP(3HPOR 1IXk000BTU) )
moardous air contaminants as defined by the Bay Arta Air Quality Management BOILER-COMP(OVER IN),"BTU)
District?
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.FT. SEP 1+
1 have read the hvzMous materials requirements under Chapter 6.95 of the 1994
Calif nam Health&Safety Code,Sections 25505,25533 and 8534. 1 understand that
r 0w building docs not currently have a tenant.land is my ospiroldallly m notify the LI I
rvsupunt of the mquirenema which must IN,met prior m issuance of a Cenifiam of V I ��s LII 1 D-,\t
Occupancy.
Owner or authormd agent Dam TOTAL: ISSUIiD BY:
OFFICE