2660 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO IfILDI .-hLR TRIAL PERMIT NO.
APPLICATIONIPERMIT PLUMBING-MECHANICAL 26660_
BUILDING DIVISION IIUIhIdING PROJKCT IDRN'fIPICA'f10N,
IhUn/1LDING ADORES SANITARY NO. AI'1'LICA'TION SUBMITTAL DAL i- .UNIT# LOT# 16
OW NI? NAMII: DoJ PHONE�� I C TRACTON'g NAME: I 1 LIC O:
({. 11 WOOD
I I/P� I#/A Q� �^f NIC C)MfN #
ARCHITECT/ENGINEER: LIC NO: AD R1LMMO)WOO Sr •I `1
CONTACT: PHONE: (/ BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB [C
PHRmdr ISSUANCE ❑ El ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
gzwzP400 Ihereby affrmtat l 3 orthnu,ira,, xIP..ions caiwes apreracommencing with �I � 1
Ia100 Swoon 7000)nf Division 3ol'the Business enA Professions Cor�and my licence is in pgNl?LS Iltl IVn-N'^�„
Fm'jE full fo let. O' UPT0200 AMP'S S 'l�
pQ,Z W Lisar Lia.p
mF+6� Dae Com.cmr 201-10(10 ANTI'S
ZOrn Zt-� ARCHII'ECES DECLARATION OVER 1000 AMPS Q.FT.FLOOR AREA SISQ,FT.
O Z—t7 I uMen(und my plans shall be used m public records.
F,y Ful SIGNS ELECTRICAL
gmNLicensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
{X�O�O I Limb,nffi.(bat I an exempt lints tba Comments License Law for the
t+ 'Or following mason.(Sechon 7031.5.Business and Profeasions Code:Any city or county 'I'EMP.METER OR POLE INST.
C w which requires a permit m immor cs,alter,irr ,m,r,demolish,or repair any struetum
prior to its issuance,also requires the applicant for such Permit torileasigned statement POWER DEVICES
¢O (bw he is Iornudpmsuant.the provisions ofihe Counselor's Licenses Law(Chapter
4XOo� 9(commencing with Section 7(100)of Division 3 of the Business and Pra(essiom Code) SWI MMING POOL ELF.C'1'RIC VALUATION
ly_, or that he is excmpt demefmm and the basis for to alleged exemption.Any violation of OU ./
L Zan
Q Section 7031.5 by y applicant for a Permit subjects the applicantto a civil penOUTLETS ahy of
t+❑Sp O t armalhan Evchundrcddollurs(S5W). I/�I
NEW RESIDENTIAL ELECfk _SQ.FT.
22 ❑ L asownernidf1wilm¢ny,arm old
inumyeeswi(hwag¢s asthei(Sec.7044,8 mriess 5'1'Ok1ES 'I TIT CON STNUCf10N
a3— will domewmrk.ands: sto rture Contractor's License
rawtis ntapply.to an,Business
and property
wh builds
Code:The Contractor's License Lew such
not apply m an owner of
property who buildsurimpmvesthereran,tmdwho does such work himselfmthrzmgh M1t. OCO GROUP RES.UNITS
own employees,pmvidwl(hm such improvements in n e intended ofoffered I'nr sole.If. 11
howercwtheavet a burimpmvemcntissoldwithinoneyearor improve
formeoose of TAI
builder will have the Emden of proving thio he did not build or improve for puryou of
ate.).
❑ I,as nwncrofthe property,nm exclusively camrnc(ingwitblicensed cnntrucmrsm QTY. PLUMBING PF.RMI YI R- II,OOD_ZONE APN
Lntswc(the project(Star.70,16,Business and Professions CMc:)The Comment's
icense Lew does not apply m an ow ner of property who builds or improves thereon,and PERMIT ISSUANCE
who contracts for such projects with o contrecmr(s)licensed pursuant to the Contractors g1.TBR-DRAIN&VENT-WATER(IiA
Neem¢Law. TEE SUMMARY
❑ I am eeempt under Sec. ,B&PC for this reason BACK FLOW PROTECT,DEVICE OU'ISIDRFFFq
SANITARY YN_
Owner Dam RECEIVI'#
•
DRAINS-FLOOR,ROOF,AREA,COND.
�/ WORKMAN COMPENSATION DECLARATION SCIIOOLTA% VN
SI ims,Coyaffrm sation awarccenifcateof con.d to thereof(Sar.
sitCertificateCnf FIXTURES-PER TRAP RECEIVfp
kers'Compensation lnsurance0recenifiedcopy mereof(Sw.3g00,Lob C.)which PARK FEB YN
covers Policy pll emyloygc's yrWcphis permit. GAS-EA.SYSTBM-I INC.,1 OUTLETS BUILDING DIVISION FEES
Company f)Vfn `h,,e TL GAS-EA SYSTBM-OVBR 4(EA) PLANCHECK FEE
is ❑ C ifed ropy is hereby famished.
C<rifed copy is filed with the city inspection division. GREASFIINDUSTRL WASTE:INTERCEPTOR GRADING RSC
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEIRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one hundred dollars(SUR) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or lees.)
I coni fy that in the performance of the work for whichthix permit is issued,l shall WATER HEA1 FR W/VENTIBLECTR
not employ any Person in any manner so as to become subject to the Workers' PAID
O Co Ipon'tion Lawsof CalifomH
ia. Date WATER SYSTEMREATING Dote Receipt#
PP
z 0 NOTICE TO APPLICANT:If.aftermaking this Certificate of Exemption.you should NEW RESIDENTIAL PI.MB. SQ.FT. TOTAL:
rV] hero.,Import o me Worker's Compensation Provisions of the Lobar Code,you mus(
Ki 7 forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FER
z CONST'RUCION LENDING AGENCY SEISMIC FEE
1 hereby affirm(Ina more is a construction lending agency for the performance of
U O the work for which this pestis is issued(Sec.3097,Co.C.) TOTAL: ELECTRIC FHE
lenders Name
F Lender's Address QTY. MECHANICALPERMIT 'PEC PLUMBING PEE
U I certify that I have rend this application and state thio We above mammalian is
4 correct.l agree to comply with all city and county ordinances and state laws refining to PERMIT ISSUANCE MECHANICAL FEE
LJ buildingronswnion,and h,rebyamhoriae reprecommivesufibis ca men¢ruponthc CONSTRUCf10NTAX
U z above-mentioned property for inspection purposes. ALTERORAUDTOMECIL
Oilm agree to save,indemnify and keep hairless the City of Cupertino against
limill'es,judgmm(s,crntsondexpemes ichmayinalywayweruee sins ea id Of
AIR HANDLING UNIT(TO 10.MC17M)
ma,of for gra i g finis t
AIR HANDLING UNIT(OVER 10.000 CFM)
Slmaur,of APplic11
/ nramr Date EXHAUST HOOD(W/DUC1)
AZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) PAID
Dine ReaiPtp
Will the applicnot or future building occupant store or handle haeurdous material
as Jefimed by the Cupertino Municipal CMe,Chapmr 9.12,and the Health cad Safety 1117ATING UN I (OVER 100,000 BTU) TOTAL:
Code,Section 25532(,)7
❑Yes El No VENTILATION PAN(SINGLE RPSID)
WIII the uppllcamnrf ummit rc bulld'ngowupam uuequipmem ordeviwswhich e
BOILER-COMP QHP OR 100,00d B'I'U) ISSUANCE DATE
• hmand us air commandments as defined by the Bay Area Air Quality Monagament BOILER-COMP(OVER 100,000 RTU)
Daudet pp5�tt
❑Yes ❑No NEW RESIDENTIAL.MECII. SQ.FT.
1 have read the hmandous materials requirements under Chapter 6.95 of the ®� CJ
California fimit&ngdoes of cur CMyhavSections aard,tht 25505. it
my nd 25534,
IityannaM that �3 ��
if the building dues not m ntsw have o itrent,that it is my seance responsibility er notify the
Occupancy.
(of the requirements which mus(M me(prim[m isevmteo of a Certificate 0f
Occupancy. lr11''
Own¢rmaumOrized on, Data ISSUED BV: s ✓T fa,V(
OFFICE