26512 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BID1. IM1 ,-h.LEARI AI. - PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 26512
BUILDING PROJECT IDEN'TIF'ICATION
BUILDING ADDRESS: � �/ /��/ SANITARY NO. APPLICATION SUBMITTAL DATE
1451 FIS r't? W A / t UNIT# �(Jys�7
OWNPJI(5tq NAME: 1Z ONE sLZ3 CONI TR �/
�I// !J `J N/C CONTROLp
RCI ITTECT/ENGINEER: LIC NO: ADDRESS: ❑
ONI'ACf: PHONE: BUILDING PERMIT INFO
Q'I'Y. ELECTRIC PERMIT FF?F.
BLDG .ECL' PLUMB
PERMIT ISSUANCE.
LICENSED CONTRACTOR'S IIECLARA'f[ON APPLIANCES-RESIDENTIAL 1 ODISCRIPf10N
cmz I herebyumtm Nat l an licensed under provisionsmCTapter9(commencing with
�00p Section 7")of Division 3 of the Business and Pro(essiorss Cade,and my license is in PANELS
WdE full to.and effect.
¢yW License Class Lit.# UP TO 2W AMPS
y Q y Date Comuctm 201-I"AMPS
ZOV,_ ARCHITGCTS DECLARATION OVER 1000 AMPS SQ,II.FLOG REA S/SQ.Ff.
p Z—Q I understand my plans shall be used as public records. M
r4 iq SIGNS ELECTRICAL.
ayy J Licensed Professional GVVV/
nKfY6 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
�'OyF I hereby affirm that 1 oro exempt from the Cannuctors License Law for the
3Qm following motor.(Section 9031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INS'Y.
(s1 rn which requires a permit to construct,slur,improve,demolish,in repair any shmi
,2iprior,.iia iseuanae,also requires the applicant fmrsuch permirto file.signedmsmumePOWER DEVICES
7'
tv ei O p that he is licensed ponm nrto the prrvi,iosa of the Commove.License Law(Chapter
aMa 9(conincinn with Section Division Sof the Bottom.and Professions Cale, gw ) SWIMMING POOL ELECTRIC VAI.UATIO
o uthat Seclum7031.5 by ny.1therefmmand the bmiefor bjacixalleged exemant to cwil ny violation of OUfLHTS-SWITCHES-FIXTURES ) /w AA s
Iz moommthan5iv anndred!dontrs Ulugrmit subjects the epplicwnoacivil penalty of !N ow
� � not more than five hundred!Antlers(SSW). NEW RESIDENTIAL ELECTR
pmpe y,mrmyemploYees with wugeaustheirsole cumpensmiort, ®�5 .Ff.
�y ❑ oche work,
and, n Q S'fOHIFS TYPE CONSTRUCTION
I
will Profession,Costae stractureCmaisnotcom's cndedm Law
dos notffend for ii,$),t oim Ewe,ss
of
and ery,wsioms Code:The Commmmrs License Lew does or apply lf un owner of
ownproenywhehprovidmproveuthimponnmmentswensuch
tended ooffietmhrmulM1 If. OCC.GROUP RES.UNITS
sin employees,providedtamsuchimprovementsin not earof durofferedfarsole.IL
boweer ,will have
brimpmvemem ishat heohinot build Inioo,theowaer TOl
builder will huve the burden of proving that he Aid not build mpm,for purpose of
sale.).
❑ I,usownersftheproperoy,umexclusivelycomracgwithlicense mnractonto Q7Y, PLUMBINGPERMIT FEE FLOODZONE APN
container the project(Sec.7014,Business and avions Code:)The Contractors
License law d......ppl,manownanfpro wholmild,vorimpmvea ammnand PERMIT ISSUANCE
who contracts for Nuch Pmjemswim ac Curtis)licensed pursuarramile ontrachasALTER DRAIN (EA)
License Law. FEE SUMMARY
❑ I Cm exempt m. ,B&P C(ort is reason BACK FLOW PROTECT.DEVICE ' D
SANITARY YN
Owner - m DRAINS-FLOOR,ROOF,AREA,COND. RECF.IPTp
ORKMAN COMPENSATI EC TION SCHOOL TAX YN
❑ Ihereby affi that l have a unificam of con IG use,or ae nifi mo( RECEIPfp
orken'Cnm n.tion Ins.., ra mnifi FlXTDNIS-PER TRAP
coversallemploy 'sundenhisp s op o S SW .ab CJ ich PARK FLe RECEIPT# N
GAS SFA.SYSTEM-I INC.4 OUTLETS
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVCR 4 HIAH PLANCHECK FEE
❑ Cenifrdatp isherebyrorm e
❑ Cenifiedcopy s filedwidithc i us divismn. GRPASEANDUSTRI.WASTE INTERCEPTOR GRADING FtiFi
CERT 'ICA9E OF EXEMPTION FROM RKERS' GREASETRAP SOILS FEE
COMPENSATION INSU CE
IThissectionncedi tbovino'ledifthe in is forms,hundred dollars i$100) SEWER SANITARY-STORM HA.200FT. ENERGY FEE
or less.)
leenlfythatinnepe comas awork for which this Permit is issued,l shall WATER HEATER WNRNT(ELEClR
nd employ any person in ny as to Ism me t t orkers' PAID
Compensation Lnwsof Cul' I i l c sat WATER SYSTPrTRBATINO Dam Receipt#
C) z Applicant
Z0 NOTICQTOAPPLICANT:ILaO rmaking his Cenifica¢oflix to,you should NEWRESIDENfIALPLIs CC SQ.FT. TOTAL:
HVbecamembj.Imt1m Workers Compensation provisions ofthe Le rCode,you must
� , forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE i-
a (� CONSTRUCTION LENDING AGENCY SEISMIC FEE
U z Ihereby affirm that them is a construction lending agency for the performance of
ELECTRIC FEE
O the work for wo
hich this posit is issued(Sus 3097,Civ.CJ
Lender's Name
U Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FtiE
I certify that I have read this application and state that the above information its
F0. comet, lagrce,.comply with all city unJ musty ordinances and uateluwe relating,. PERMIT ISSUANCE ^ MECHANICAL FEF.
Lo) buildingmnstionion,and hereby authorize represenutivesmfoaiscity mercer upon the
U 7 above-mentioned pmpmy for inspection purposes. ALTERORADDTOMCCH. CONSTRUCIIONTAX
:7
Wo)agree to save,indemnify and keep harmless the City of Cupertino against I I
liabilities,judgments,costs andexpenses which may' any way ucerue against said City AIR HANDLING UNIT(TO 10,00)CFM)
in cmnscgt once of granting ofthi emit.
/ rad AIR HANDLING UNIT(OVER 10,(0X)CFM)
Signammof Applicant/Commctor t. EXHAUST HOOD(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOSURE yl' BEATING UNIT(TO IW,OW BTU) Dom JamuptI,
Will the applicant or future building occupant core Or hallon hazardous material HEATING UNIT(OVER I W,IXNI BTU) TOTA
as defined by the Cupertino Municipal Cade.Chapter 9.12,and the Health and Safety
Code,Section 25332(a)P
0Yea X No VENTILATION FAN(SINGLE RESID)
Will the epplicummr is as building by the Bay
equipment ordeviceswhichemir
BOILER-COMP OUT OR 100,00)BTU) ISSUANCE DATE
cardous air contetrdnanu m defined by Ne Bay Area Air Quality Mnnngetnenl BOILER-COMP(OVER 100,010)BTU) (0 %
ulricl?
❑Yes K No NEW RESIDENTIAL MECH. SQ.FT. i]
I have mad the hanrduus materials mcp ramemu under Chapter 6.95 of the SEP (� /f
California Health&Safety Code,Sections 25505,25533 and 25534. I understand that of
if the building does not carte tlyhuv amour,no it is myresponsibility,to notify the
cecupano sf thet�,um men hick must k met prior to issuance of a Cenificase of CI V. ,.Lu.LuOccupanc ♦ I Y yr df�
��-• )
OwneuwhorizeJ agent Dan T A ISSUED BY-'
nn
OFFICE