26885 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OFCUPERTINO numnN�;=B7ECHA CX1ICA vBRMrrNo.
APPLICATION/PERMIT PLUMNINC-MF.CHANICAI. 26885
�DUILUINC.DIVISION BUILDING PROJECT'IDENTIFICA'T']ON
BUILDING ADDRESS: ���'aa �/� SANITARY NO. APPLICATION SUBkinTAL DATE
0 D � L ♦rV . UNIT LOTp
OWNP S AMI:: IL+ gLrf� PIIONIi: C CfOR'g NAME / LIC NO: 1 N/C CONTROL0
\kCI11ICC1'/IiNGINEER: LIC NO: ESS V♦r l/..N��e>tlwB^.
Gq. e%1
'ONTACI': PHONE: h
QTY �. .& w, :' ELEC'T'RIC PERMIT'..r.� ,-=. - FI:H QBOILDINGPBRMIT INFO
.x r i f a BL CT PLUMB MECH
PERMIT ISSUANCE /' �'9C I�
LICENSED CONTRACTORS DECL'Chape ON APPLIANCES-RESIDENTIAL ^ .,�� JOB DESEL IPIIUN` lO\
Cat Thereby ufErm lbu cenuJ ander prnvisionsnfCbaptcr9(commencing with / ^/res
ts100 Section]INg7 of ron3of tM1e Business and Professions Code,and my license is in PANELS
y,Ma W, full force and
QQUYYUUII Licenx Class Lic.p UP T0200 AMPS
v~sGrr- Dom Contractor 201-1000 AMPS
F-y Z_ ARCHITECTS DECLARATION SQ.FT.FLOOR AREA $/SQ.pir.
O2y❑ I understand my plans shall be,used as public records. OVER IgX)AMPS
F.m t= SIGNS ELECTRICAL
QyEJ Licensed Professional
�'Pt OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XO I hereby affirm that 1 am exempt from the Contractor's License law for the
W3g� following enter.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE WST.
FkOg which requires a permit to construct,after,improve,demolish,or repair any structure
� Yg pmar oits iasurione' mosilmoesmeapplica.tforsuchivrmiuofile.aimedstatement POWER DEVICES
[nail Q O that ha Is licensed pursuant to the provisions of Contractor's License Law(Chapter
tLp,oC 9mommniving will,Section]000)of Division]of the Business and Professions Code) SWIMMING POOL ELECTRIC - VALUATION
iyC M_2 or 111he is exempt tbernfrom and lhebasis for theallegedexemprind Any violation ofUTLETS-SWITCHES-FIXTUR85 / 'bib
-< Scainn 7113 LS by any applicant fora permit eubjecte the uppliconuoacivil penalty of L
O not morolhunfivehundred Jolles($500). NEW RESIDENTIAL HLECTR _SQ.FT.
gy p% ❑ LasownenVdthei co a kno apinyeeswithwagesasthein(Sec.7W,
Bad ion, STORIES TYPE CONSTRUCTION
L will dotbework.and the income ureisnnex License
fs tom.Su.7B44,Business
and Professions Code:The veathectors License law uch not apply o an owner of
poperywyecs, vide pmvuthimp semens notihworkorefffofm ugh We.his
ownemplayeeailding rimprouchimis sold within
ne earof ompletweJ theowa If. OCC.GROUP R13.UNITS
builder%rhe building ori en of proving
is hath within one yew ofcompletion,purpose
of
bale.). will have the burden of proving that he did rant build or improve for purpou of
sale], -'
❑ I,uownutfthe property,amexclusively, contracting wiNLicemeJ commendationQTT Y:YJs PLUMBINGPERMIT FEF; FLOOD ZONE APN
construct the project(Sec.7044,Business and Profusions Code:)The Contractor's
License law fres not apply toanownerofpropeny whobuilds or improves thereon,and PERMIT ISSUANCE /
who contracts forsuch projects with acantracmr(s)licensed pursuant to me Contractor's gLT[R-DRNN&VENT-
Licenx Law. WATER(FA) FEE SUMMARY
❑ I am exempt under Sec. ,B&PC for this reason PACK FLOW PROTECT.DEVICE UT,IDE DLL.
SANITARY ' Y_N_
Owner Duda DRAINS-FLOORROOFAREA,COND. t RECEIFTM
, ,
WORKMAN COMPENSATION DECLARATION . SCHOOLTAX Y
❑ lherehy affirm that l have a cenificam d emsent to self-insure,or a certificate ofRECEIPI'g
FIXTURES-PER TRAP
Workcn'Comnsationinaamsce annit. ifcd ropy thcrrnl(Sec.JB W,Leb CJ which PARK FEE Y N
ns ell emplmye<'r undo this pcnnie GAS-EA.SYSTEM-I INC.4 OUTLET'S RDIVA p
PalicyM - BUILDING DIVAI F
Company GAS-EA.SYSTEM-OVER 4(FA) PLANCHECK FE
31
❑ Cenifedcopyishembyfumished.
❑ CenifiedcoW is filed with the city inspection division. GREASHJINDUSTRL WASTE INTERCEPTOR GRADING
CERTIFICATE OF EXEMPDON FROM WORKERS' GREAMITRAP SOILS Fkn 4,
COMPENSATION INSURANCE
This section moreal completed ifthe permit is forone hunderddollan($100) SEWER-SANITARY-STORM F.A.20oFT. HNRRGY
or less.)
Icenifyflamo , immune for whit This permit is issu ,Ishall WATERIIHATFRW/VHNT/F.I. CTR
oat employ any rs any in so s been hj t PAID _
Comlenslnion sI T mie. WATP.RSYSTEMaRDate e' p p
Arpbeantrz X`111—
z NO'I'ICH lU PLIC :If,a er making this Cutifcamof E option, shoal NE 1351D1?NTT 1 I B. SQ.FT, TO'fAl.:
torment,subject to the Worker's Compensation previsions of the Labor Code,you must
forthwith comply withmich provisions.,this permit shall be domed revoked. BUILDING FEE
Z CONSTRUCTION LENDING AGENCY
I hereby affirm that them is o construction lending agency for the performance of SEISMIC FEE
UO the work far which this Permit is issued(See3197,Civ.C.) ELECTRIC FEE �♦
lender's Name PLUMBING E
F lender.Addrea. QTY; j MECHANICAL PERMIT 'F17H
U 1 cert
certify that I have sad this application and state that the move information is
correct.I some to comply with di city and county ordinances and state laws mlating to PERMIT ISSUANCE MECH VAL FEE
F-" building construction,and herebyradmnze representatives oft scitytacnteruponthe CONS UCTION TAX
U z move-mentioned .,my for inspection purpose. ALTER OR ADD TO MECH.
(We)agree to s indemnify and keep hwmless the ity of Cu nim against
Iiabilities,juAgmcn ,c us andexpe hlchmayinsnyw ar, Inn AIR HANDLING UNI'T(TO I(LOW CFM) is W ✓�
me". - or a e rdn Ing of pe - ♦(/CJs/
IR HANDLING UNIT(OVER-H,000 CPM)
Signulur Appllcu /Conroe r Dam I:XIIAU$'f I{GOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Dam Receipt
Will the applicant or future building occupant store or handle haaardous material HEATING UNIT(OVER IOO,fNN1 BTU) TOTAL:
as dcllnW by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)7
11 Yes 13 No T MVE '11.A'I'ION FAN(SINGLE RFSID)
Will theapplarmorfuore building occupant use equipmentordeviceswhich emit
BOILER-COMP(JHP OR I00,010 BTTI) ISSUAq(Cr DAVE
:Anus air contaminants ss defined by the Buy Amu Air Quality Management BOILER 100,000 BTU) ��� q
triet7 1 8 1994
❑Yea ❑No NEW RESIDIiNT1AL MECH. SQ.FT.
1 have mad the hazardous materials requirements under Chapter 6.95 of theTb
Culifamia lleaVh&Safety CrsJe.Seniors 25505,25573 unA 25534. 1undemandtho //Y of VUf Cf7//fVIJ
Hthe building does not currently have a cenunL that it is my ospomibilay o notify the
capon nl the rcyuiremems which must o met Tetra'm Lasuunee of a Certificate of
Onerorawhorize
wdagea Dam g ISSUED BY: