26425 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINp
APPLICATION/PERMIT PLUMBING E T[DEN NICK 2 6 4 2 5
BUILUIN(i DIVISION
BUILDING PROJECT IDEN'1'IP'ICATI(]N
BUILDING ADDRESS: 1 I SANITARY NO. �APPUCVPONSUBMITTALDATI
S w4v, act TAI \ L.. UNIT. LOT
OWNI:RSN li: PHONE: CONTRACTOR'S NAME: LIC NO:
CIC- 61M v - 3-D36b 24954 " CON O1N
•ARCfII /ENGINEE]t I LIC NO: ADDRESS: ElB69
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL I JOB DESCRIPTION
pceZ I hereby affirm that l am liceneduader provisionso amptv9(commencing with
00 Section 7")of Division 3 of the Business and Profusions Coda and my license is in PANELS
y full force and effecv p �-n
Fyco Date class �- Liu. IS4� UP T0200AMP5 yv`
,0Dy Dao Gantmmm rY 201-1000 AMPS
z000 ARCHITECTS DECLARATION OVER IOW AMPS SQ.FT.FLOOR AREA SISQ.FT.
O Z,4 0 I understood my plans shall Ix used as public records.
w SIGNS ELECTRICAL
Licensed Pmfia.iaml �a
-�yzQ OWNER.BUILDER DECLARATION SPECIAL CIRCUffmftsr �A 1
XO W I hereby affirm Nal I.no exempt from the Conunmoi s License taw for be
m�Oy following rwsoa(Section]OJLS,Business and prefectures Code:Any city or county TEMP.METER OR LEI t ��\
F11mJ which requires n permit m construct,alter,improve,demolish,or repair any structure KW¢E prior to its issuance,also reyvims file applicant for such permit to file a signed statemern POWER DEVICES I 1 ,1
W W 0 that he is licensed pursuanuo the Provisions of the Contractors License Law(Chapter
,E:0 9(commencing with Section of Division 3 of the Business and Professions Code SWIMbeNGPGOLEECfR
,0 ) ) VALUATION
m-.m or that he is exempt therefrom and the Wsis for the alleged exemption.Any violation of .,.,�p
I-•Z> Salian]031 S by any applicant for a perinklubjecm the applicant to a civil penalty of OUTLETS-SWITCH -FIX npao
SSp¢ not more than Eve hundred dollars($500). NEWRFSIDENF1AL _SQ.PT.
caSTORMS TYPE CONSTRUCTIOp
yFo ❑ LasowncroHhepropeny,ormyemployecswithwagexasthevaole mperamon,
22 will do the work,and the smorm is not intended or offered forsale(See 704.Business
and Pec essiona Cede The Contructor'a License Law does not apply to an owner of
property who builds or improves themon,and whodoes such workhimselforthrim bhis
employecs,providedthatsuch improvetantsate notimrndedmoffered Tarsale.
If, OCC.GROUP E-Fl
however,the building or improvement is sold within one ycuofcompledon,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ Las owner of the property,am exclusivelycouracting wird Licensed contractors to QTY. PLUMBING PERMIT FEF, h1OODZONE
onstruct the project(Sec.7014,Business and Professors,Cade:)The Contrscm's
Liccna Lawdcesnot apply loan owscro(Fropcny who builds m impmvcsthcrson,and PERMIT ISSUANCE
whence Law. AL
projects with uconvecmr(s)licensedpunuanuothe Contractors ALTER-DRAIN&VENT.WATER EA FEE SUMMARY
License Law. (� )
❑ 1 ant exempt under Sec. ,B&P C for Nis reason BACK FLOW PROTECT.DEVICE IITSIDIi ,[s
SANITARY Y—N
—
WORKMAN
Dom DRAINS-TOOR,ROOF,AREA.COND. RECEIPT'.
WORKMANCOMPEcateIONDECLfsRATION SCHOOLTAX Y N
❑ Thereby affirm than M1avm c<nificam ofof consenuo ttlbiaure,oreccnificate of FIXTURES-PER TRAP RECEIP #
Wmasid Carp Ztionlnuranec ore certified copy thereof(Sec.J800,Lab C.)which PARK ISE Y N
colics all unplPY�'a ypdpuhi yni� GAS-EA.SYSTLM-1 INC.4 OUTLETS RECEIPT'#
ComPolpany
PP 'Y`li L BUILDING DIVISION FEES
Cnntpuny L h 'l�I
❑ G[rtlEed copy iv hereby famished. J GAS-EA.SYSTEM-OVEftd(LA) PLANCIIpCK FEE
❑ CciifiW copy is filed with the city inspection division. GREASE(INDUSTRL WASTE INTERCEPTOR
GRADING EEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GR122ASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not bt completed ifthe permit is forone hundred dollars I$IN) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or I..)
I certify that ratio perfmmanee of the work for which this permit is issued,l shall WATER HFATER WNGNTAILECTR
not employ any person in any rammer so ex to become subject to the Workers'
PAID
OZ Compcnution Laws of Celifomie. Dare WATER SYSTEM/1'RFATING Date Receipt#
Applicant
Z2 NOTICE TO APPLICANT:If,after raking this Cenifccam of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
rVJ become aobject o the Workers Compensation provi,amoofthe Labor Cede,you must
� ; forthwith comply withsuch provisions or this pecrit shoR be deemed revoked. BUILDING FEE
Wf—
y CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm Nat them is a coalraction lending agency for the parkarnance of
U O the work for which this pernil is issued(See 3097,Civ.C.) TOTAL: ELECTRIC FEE
Lenders None
Q U Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I certify that I have mad this application and state that to above information is
correct.l agree to comply with all city and county romances and stale laws relating to PERMIT ISSUANCE MECHANICAL FEF.
F" ,,G building ennslrvction,and hereby authorize representatives ofthis city to eater upon the
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(we)agree to save,indemnify and kap f unless the City of Cupenino against
liabilities,judgments,casts and expenses which may in my way imeme against said City AIR HANDLING UNIT(TO I 0,000 CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10.000 CFM)
Signature of npplicanVConlrmor Date EXHAUST HOOD(W/DUCD
PAID
I IAZARDOUS MATERIALS DISCLOSURE HEATING UNIT('f0 10),000 BTU) Dau Receipt#
Will the applicant or future building occupant store or handle hamrdous material
asdcfincdbylhe Cupertino Mu ' pal Code.Chapter9.13,anddte Heallhand Safety HEATING UNIT(OVER IN."BTU) T T
Cade,Section YaJ4(a)] No VENTILATION PAN(SING LE RESID)
BOILER-COMP(3HP OR IW,000 BTU) ISSUANC TE
Will theapplicanlnrfmareb Zavacup". equipmem ordriccs which emit F p O D
hazardous air comamimmts as eBit to the Bay Area Air Quality Management BOILER IOO.tX10 BTU) W Y..
In I'1 ❑❑//II C ((��
is c ❑Yes No NEW RESIDENTIAL MECH. SQ.FT. WAY 519,)4
1 have read the hamrdme,materials requimments under Clients,6.95 of the
California Health&Safety Code.Section 25505,25533 and 25534.1 undcrsund that
if the building docs our curcntly have atenent,that it is my rcspnnsibilitymnotify the CI1Y Ur wt,
accupunt ,110,reyu emeKs which must a m I nor Q oune a of a Cerlificale of
Occmpency.
Own u h zed agem Dam TOTAL: ISSUED BY:
OFFICE