26281 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BIRIluiac-b".1TRIGa. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICA[. C O
BUILDING PROJECT HIEN']TFLCA'HON v o
BUII.DI�N/IGQADUR\F/SS: SANITARY NO. APPLICATION SUBMITTAL DATE
1 1�''•` 4.aow UNIT# LOT# ('S
001cl NAME:g!Lb ��Y+, PHONE: C RA 'OR'S N +: 0 0 t.4 NO
j.: O-3 N/C � COONNTROL,#
ARCIII'IFUI/F GrCQlbAAfaO EER: �/IM LIC NO: A
MEAL �- �Itw► w HITVM
CONTACT: PHONE: "# 'v'.,• 'u 5"- ubd. s'„
� I fz� QT{Y.=s �r-��E6ECIRIGPBRMIT FEE BUILDING PERMIT INFO
�NI 6I V ar J`�`+ r I3b� PER IT ISSUANCE I r BLDG ELECT UMB CU
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
pyZ I herebyieffimOhat l am licensed underprovisions ofatipmr9(commencing with 1 DESCRI ('ION
uF10W0 Section 7")of Division 3 of the Business and Professions Code.and my license is in 1 PANEM
C full force lass eflect.
Z ns
1\
FLiceee and Lic.p IIP 100 PS
mQy Dna Common 20AI"API
ZO y� ARCH TfiCPS DECLARATION O 1 A SQ.FT.FLOOR AREA $/SQ.ET.
O Z—G I undenmend my plans shall be used as public records.
6yfJLicensed)Professional S SP.L ICAL
ay C< OWNER-BU(I.DRR DECLARATION SPE LCIRCUIT/MISC.
Sd5�0p�,V 1 hereby affent Wet 1 am exempt from the Contract a Liceme Ahp�r D13 C, following Mason.(Section 0031.5,Business and Professimr Cod e:Any ciMP.METER OR POLE DIST.
F'E1�g which rtyuircsapemdr to cmnmm<L elmr,improve,demolish,on repair a -74
�d ¢� prior to its issuance,also requires the applicant for such perm itoo densignPOWER DEVICES
O that he is licensed pursuant m the provisions or the Connector's LicenseL
of14 9(unmmen1ag with Semlon9fo)( irf Divioisn3ofthe Buslnessadd Pmfessmis Code) SWIMMING POOL ELECTRIC VAI 'PION
Iy_y or butte,is exempt therefrom and the basis for alleged exemption.Any viol.tlonof � ��e T
6
Section 7031.5 by any applicant for u permit subjects the applicant to a civil penally of UTLETS-SWITCHES,FIXTURCS S
t more than five hundred dollars($5(X)). NEWREI DENTIALELECIER _SQ.FT.
e' m n❑ 1,.smwnmoftbepropeny,armyemploywswithwagesmlheirsolecompematiom, STORIES pSTRUCf10N
i3— will do the words,and Wemmaure is not intendedoroffered hostile(See 7194.B.xiaess
and Professions Cole:The Cmmmmors License law dors not apply to an owner of
pmpcnywhobuildsorimpmvesIhemon,andwhodcessuchworkhimselfortu ughhis
own employees,provided that such improvements arenot intended ormffered fee We.If, OCC.G RFS.UNITS
however,the building or improvement is sold within one yemafcompletion,theowner- 0
builder will have the buNen of proving that he did not build or improve for purpose of
rasa)
QT u V ('PLUMBING PERMIT "iFEE 00 ZONE,. APN
❑ I fth prnpeny,umexclusrvelycontracungwith license conwmo t opt . ,
construct do,11.1co(Sec 7044,Business and Pmfic.mns Code) .'be Contrmm x
I.aenulaw docs not apply to anownerofpropcny whootal"orimprovesthereonand PERMIT ISSUANCE76
who contracts for such projects with acontrmtons)licensed pursuant to the Coduarrns ALTER-DRAIN&VENT-WATER(FA)
Liceme Law. FEE SUMMARY
❑ 1 am exempt under Sec, ,B&P C for this mason BACK ROW PROTECT.DEVICE Omni
SANITARY Y L N
Owner Dam RECEIPT#
DRAINS-FI.00R,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION DRAINS TAX YN
❑ Iherehy affirm thmlhave aceni0eme of conxnumsel6insurr,oreccomficam°f FIXTURES-PER TRAP REC(i1Pfp
Workern'Cmmpensation lnsumnec nrecenifiedcopy thereof(Sec.380FLub C)which PARK FEE Y N
ens vl l employee's under this permit. GAS-A.SYSTEM-I INC.4 OUTLETS RECEIPT#
./ Policy# BUII.DING DIVISIO FEF.
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHHCK FEE
❑ Comfied copy is hereby famished.
❑ Ccnificd copy is filrA with the city inspection division. GREASIVINDUSTRI.WASTE.INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This sec0mmardnm be completed if the permit is for one hundred dollen($100) SEWER-SANITARY-STORM EA.HAFT. ENERGY FEE
or less.)
I cenify that in the performance of the work for which this pronit is issued,Ishall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to become subject an he Workers PAID
Compensation Laws of Califomn. Date WATER SYSTEM/IREATING Ulm Receipt
O Z Applicant
ZZ�-1 .0 NOTICE TO APPLICANT:ILaOer making this Catifirumof Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
t' :-I her otnesubjeaam the WorkerLab
Workers Compensation provisions of the or Code,ymm must
w
FFFa'" > forthwith comply with such provisions or this pend,shall be deemed revoked. BUILDING
0. Q CONSTRUCTION LENDING AGENCY SEISMIC ME
7 z 1 hereby affirm thanberc is a i om uctim lending agency for the perforemme mf
U O the work for which this permit is issued(S..3097.Civ.C.) T A ELECTRIC M-E
I.cmd.ex Name - PLUMBING FEE
O U LenJeraAddresa QTY. MEC 11ANICALPERMIT FEF.
1 cenify that I have read this application and state that the above information is ` MECIIANICAL LLE
cored. leans In comply with all city and county ordinanem and slate laws miming to PERMIT ISSUANCE. �i
building construction,and hereby authorize nepreserand,usofthis city m enmrupon the CONSTRUCTION TAX
V Z .love-nermimned property for inspection purpoass. AI.TL•R OR ADD TO MECH.
(We)agree to save,indemnify and kap harrtJes City of Cupeninn ngainx
lialevies,judXments,comsandexpenseswhich may in y by
accrueagainst said City AIR HANDLING UNIT(TO I DIX0 CFM)
ini, sequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
;igraame of Applicant/Contmmmr I I Dad EXHAUST FLOOD(W/DUCO
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building occupant store or handle hazardous material
ax defined by the Cupenin i Municipal Cade,Chapter 9.12,and the IIcahn and Safety IIEATING ON IT OVER IOO,LyX BTU) 'f00'AI.:
Code,Sermon 25532(e)1
El Yes El No VENTILATION FAN(SINGLE.RHSID)
Will the applicant or future building occupant use equipment ordcvica which emit
BOILER-COMP(LHP OR 100,001)BTU) ISSUANCE DATE
arardous air conmminams as defined by the Bay Ates Air Quality Management BOILER-COME(OVER 100,000 BTU) }s {i '
ixWn1 Y' P4
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.P.
1 have mad the hszandmus materials requirements under Chapter 6.95 of theppR 19 1994
California Health&Safety Code,Sections 25505,25533 and 25574. l understand that
if the building does not currently have a tenant,that it is my responsibility to notify the
ceupu i al the requlrememr which most bra mm prior m Iommee or n Ceni Em
co of
oaatpl,ney. CITY II i
Owner or emhorized.gem D ateAL: ISSUED BY:
OFFICE