26683 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO -G-ML CHANT A, PERM"'"°. 26683
APPLICATION/PERMIT 1'LUMBIRG-MECIIANICAI.
BUILDING DIVISION BUILDING PROJECT ID4:NTIFICATIO\'
BUILDIN�Gi//ADDRESS
,:,�(1 I' •/t (//1 SANITARY NO. APPLICATION SUBMITTAL DATE
/ ag+ ✓1 (v{/ I/ • UNITM LOT#
OWNERSNAME: /J PI q CON R'SN E: LIC NO:
_I/ NIC CUNUROL#
RC1f11I:CT (NEER:
LIC NO: ADDRESS: I ❑
'ONTACI': PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
L w^'� L BLD ELECT PLU❑M9 MI❑CII
Iq 1--eqPERMIT ISSUANCE
LICENSEDCONTRACfOR'SDECLARATION APPLIANCES-RESIDENTIAL
Ihereh affirm that l amliectsed under .>•/ JtO�BDESC ION
p¢Z yet provisionsof Chapter9(commencingwilh syl(G� �f/+4.4r
4100 Section 70N00)o1 Division the Business and Profes t0s and my liameis in PANELS /
FF 014.. full force and a tett. Ford
n} 'r�J)y.a
FZW Its Cfs Lic.# 14/ `� • UPT02WAMPSI /J�/� 1
h=y Date Contractor '{x�.ate 201-EXQ AMPS (/t
ZONZ A CIIITECfS DECL T V OVER I"AMPS SQ.FT.FLOOR AREA g .r.
O Z L O l senders rad my plans shall 4 used as public r
L!=w SIGNS ELECTRICAL
jLivensed Pod,,sionul
d'dc'Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XLou F I hereby artirn that I tun exempt from the Comuacter's License Law for the
µl3 a m following reosom.(Section 7031.5,Business and Professions Coda Any city or county TEMP.METER OR PULE INST
t ON; which requires a Permit to construct,arm,improve,demolish,or repair any structure
F.WY$ prion.itsransom.also requires theapplicant forsuch permit to file a signed smtement POWER DEVICES
W K a0O that he is licensed pursuant to the Provisions ofthe Contractor's License Law(Chapter
aXo 9(commencing w lib Section 7000)of Division 3.],he Business and Professions Code) SWIMMING POOL ELEfRIC VALUATION
yl_y or that he is exempt hctefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWIT FIXTURES �,>00 sJ'
t Z> m Section]031.5 by any applicant for a permit subjects the applicant a civil Penalty of
Exo not more than five hundred dollars(S5W).
wt:,, ❑ Lasownerofthe proper NEW RESID LELECIR _SQ.FT.
y,nrmyemployeeswith wages theinolecompensation, STOR7E.S TYPE CONSTRUCTION
a3— will Bothe work,and the structure is not itnendedoroffened for sale(See.I0,4,Business /
and Professions Costs:The Commcmrs License Law does not apply m an owner of
popery who builds ser improves theom,and who does such work himself rer through his
ownemployms,providMNatsuchimprovementsummtintendedaroffere f6r e.If, ..GROUP RES.UNI IS
however,the buildingor improvement is sold within one yearo(completion,theowner- TOTAL: Q
builder will have the burden of proving list he did not build or improve for purpose of U
sale).
❑ I,samatirofthe property,amexclusively contracting with licensedconractorsto QTY' PLUMBING PERMIT FEE LOO ZONE "N
O construct the project(Sec.70414,Business and Professions Cade:)The Contractor's
License hawdcesnnt apply non nwncnal property whnbuilJsarimprovcsthereogand PERMIT ISSUANCE
whoconmmts forsuch projects with aconameor(s)licensed pursuanuothe Contractor's
Lice.Law. ALTER (EA)) PEE SUMMARY
❑ I am caemPt underSa. D&P C for this reason BACK FLOW PROTECT.DEVICG UTSIDI:PEES
SANITARY Y N
Owner Date RECEIPfp
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR.ROOF,AREA,GOND. SCHOOLTAX — YN
❑ Thereby affirm thetlhavu acenificmc of conxmto self-insure,oro cenific+re of l RECE_In
Worken'Coan do Insurance fiedcopythemof(Sec.3SW,Lab C.)which FIXTURES-PERTRAP 11
RK I YN
coversall cnupl c' d GAS-EA.SYSTEM-1 INC.40 LES V :. s>r �• RECEIPT
Policyp _ nBUILDING DIVISION FIT ES
Company GAS-EA.SYSTP,M-OVER 4 HT 1` 1 I^t), t
Cl Certified copy i. reby misbul. L V L E K E
❑ Certified WRY is Bled w the city inspection division. GREASFJINDUSTRL WA TEI RCEPfOR / Ir,FIiE
CERTIFICATE OF EXEMPTION PCOM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This aceto hand not be tom ted ifthe permit is forone hundred dollars($100) SEWER-SANITARY- ORMEA2WFT. ENERGY FEF,
leciifythatinthe Perf nn a (thew kfo vhichthispemi Isisim WATER HEATERW ENT/ELECTR
not employ any person n y k SO become o t t
O z Compensation Laws of 1' f�'e ate WATER SYSTE /TREATINGAppliPAID
Coot/ rs
Date Rcccipt#
Z 0 NOTICETOAPPLICA Laftermaking r Ce sora of Eseat on,youshould NEW RESID AL PLMIL SQ,PC TOTAL:
^F fn becomesubjeciminc work sCompensalio o softhe Labor Coda,you must
� ; forthwith comply with such provisions or this vit, Ilbedeemedrevoked. BUILDING FEE
�w
y Q
CONSTRUCTION UEbIDING AGENCY SEISMIC FEE
Z 1hcmbyaffirm quit them is construction lending agency for the performance of
V O tboworkfor whidnM1is permit is issued(Sec.309C.)],Civ.CJ TOTAL: ELECTRIC FEE
Isnders Name
Q U Lenders Address QTY. MECHANICAL PERMIT FEF PLUMBING FEE
I ani fy that 1 have read this application and state that the above mforamore is
correct.l agree to comply with all city and county ordinances and state laws relating to MMECH—SQ.
T ISSUANCE MECHANICAL FEE
F-' � buildingcansweGon,and hereby+uthonse mprtsentativesofthis city menterupon the
U 2 above-notak ed propmy for inspection purposes. ORADDTOMECH. CONSTRUCIIONTAX
(We)ul ce to u.Indcmni and keep harmless the City of Ca y,no a ainst
41�
' mem,c sts ande eswhichmoyin anywayaccmee ainsts' Cby NDLING UNIT(TO 10.000 CFM)
ofd min permitNDLING UNIT(OVER 10"CFM)pp ica VCbnva De ST HOOD(WJDUCf1
PAID
IIA%AR I MA' IALS UISCLOSUBE NG UNIT IW,(N10 BTU) Dam me
p#
the applicant or future wilding occupant store or handle brardens material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety G UNIT IW,OW B ) T A
Code.Section 25532(0)]
El Yea 0N LATION FAN(SINGLE SID)
-COMP(3HP OR ,000 RTU) ISSUANCE DATE
Will theapPlican or future building occupant use equipmemordevices whichemith:vardous air conmmmams as defined by the Bay Arca Air Quality Management -COMP IOV IW.Oo0 BTU7 A
District? ❑Yes ❑NoESIDENT 1.MECH, SQ.Ff. JI L991 have.cad the hazardous materials regalre 533 under Chapter erst of the {I1i7 1991
if the uil Ingdo& ortmCode,Sections25505,25533and25534.(understandNatCITYiftruebuildingdoesnotnients lyhaveamnatn,thatitismyssuanceoflt enotify theb (/(- (lut'tHUry
xaupam of tlm rcyuimmcn¢which mus M1c mel Prior w issuance oft Certificate of
Occupancy.
Owns m authowed agent Date
TOTAL: ISSUED BY:
0FFICE