26295 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPINO IIIMrS`17-EC. A PF.RMITNO.
F.RT
BUILDINGn FRTN APPLICATION/PERMIT PLUMBING-MECHANICAL. n C
BUILDING PROJECT IDENI'IF'ICA'I']ON J J
HUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
WQ r UNI'D LOT ci-CONH 1/
OW F.RSNAME: IONC: NIRA R'S NAME: IC NO: 1����,
�-+ �, , O NIC CONTROL p
ARCHITECI'/ENGINHER: LIC NO: ADDRESS
2 Q v
CONTACT: PHONE: a 'hd u Y '+_ ' ' RUILDINO PERMIT INFO
UNQT}Y. ELeCfRIC 1 FRM1T r? FEE
,1. _,i r BLDG ELECT PLUMB MRCH
PERMIT ISSUANCE ❑ ❑ 0 ,^(
LICENSEDCONTRACTOR'SDECLARATION APPLIANCES-RESIDENTIAL LOB DGSCRIPI'1O�\�
OCZ Ibercby affirm that CENSE CONTRcensed Ander CTORS
RATE 9(commencing with
W00 Sardon70fabc,'Division 3ofthe Bueinessand Pmfcado.s Casle,and my license is in PANES
yy'UfF. full forty vol affect.
_,, License Class Lic.N UP TO 200 AMPS
m 6 ti
Data Contractor 201-1000 AMPS
20oniK ARCHITECTS DECLARATION OVER 10(10 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
0 z- 1 understand my plans shall be used as public records. n�I
Fvra.La,43 SIGNS ELECTRICAL 7 /� t'.., E ® a
6 >71 Licensed Professional
Ka96 OWNER-BUILDER DECLARATION SPECIAL CIRCUEDMISC,
wa:p. I hereby affirm Nat 1 an exempt from the Contractors License law for the 's, M� G
W 3 a.y following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.ML•TER OR POLE INST.
yyy"�j'
1h a, which re
quires a permit to construct,alter,improve,demolish,or repair any moisture b
TX prior toil issuncs,also requires the applicant for such permittorileasigned statement POWER DEVICES DAT
60 that he is licensed Pursuant to the provisions of the Contractors License Law(Chapter
aao� 9(cormnencing with Section 7")ofDivision 3ofthe Busineaaand Pmfevions Cade) SWIMMING POOL EL.ECIRIC VALUATION
or that he is exempph mmurn and Ne basis for the alleged exemption,Any violationaf OUTLETS-SWITCHES-FIXTURES
Hyo Sardinia 9031.5 by any u mcton fora permiimbjeels the apPlimum toacivllpenelty of
$ t mom then five hunlual do][.($50d. NEW RESIDENTIAL ELECIR _SQ.FT.
C F`o ❑ I,asownerofihept ny,ormyemployeeswithwagesastheia.lecompevsadon, STORIES TYPE CONS'IRUCI'ION
will do the work,and the income is not intended or offered for sale(Sec.7044,Business
and Professions Cole:'rhe Contractor's License Law does not apply to an owner of
pmpcny who builds or impmvas thereon.and who does such work himselfor through his OCC.GROUP RES.UNITS
own employees,provided that such improvementsre anot intended or offered Intrinsic.If,
however,the building or Improvement is sold within one yecrofeampletion,the owner- T
builder will have the burden of proving that he did not build or improve for purpose of
sale.). >,.:I r. i . .
❑ I,asownerofthc n QTY. PLUMHINC PCRMIT FEE FLOOD ONE APN
property, conProfetracting Code:)
Contractor's t +,, ,} .
kens
construct the project(Sea]fano Business and ywho build Crimp ova theme.an's ..
License Lawdoes nm apply towownerof propmy who builds or improves thereon,and PERMIT ISSUANCE
whocmnmcss fnrsuch projarswithaconhacbKs)liaised Pursuantwthe Conrtactor's ALTER-GRAIN&VENT-WATER(EA)
License Laos. FEF,SUMMARY
• ❑ 1 and exempt under Sec. ,B&P C for this reason OUT, DEF EES
BACK FLOW PROTECT.DEVICE SANITARY Y_N
Owner Dote pRA1NS-FLOORROOFAREACOND. RECEIPT0
, , , .
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ihaeby affirm thatlheveacmiBcme of c.nunuo self-insure....cardlicate of RI?CEIPI'p
Wmkmpen
'Comssumn lw
nmacema cenifteicopy thereof(Sm.3800.Lab C.)which FIXTURES-PER TRAP PARK FEE Y—N
—
covers
all employees under this permit. GAS-EA.SYSTEM-1 INCA 0UTLEf$ RECEIPT 0
J
Policy It BUILDING DIVISION FEES
Co reany GAS-EA.SYSTEM-OVER 4 HA) PLANCHECK FEE
❑ Ceniftedcopynherebyfumished.
❑ Cerlifed copy is filed with Ne city inspection division. GREASEaINDUSTRI.WASI'EINTF.RCE"OR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
Ghissectmatiecl no,be,completed Hit.fa mit is furore hundred dollars(5100) SEWER-SANITARY-STORM EA.2001 ENERGY FEE
or less.)
I certify that in the perfereanee of the work for which this .I,is issued.Is hall WATER HEATER W/VENT/ELECfR
not employ any person in any manner%91 to been jest to the Worker, PAID
C. penin.ptJ a� �fC�dd�a Dare r�—ZN WATER SYSTEM/BEATING Data Receim a
O z APPlica t it�:s..� De
0 NOTICE.TO APPLICANT:If,after making this CardiBcate of Exemption,you should NEW RESIDENTIAL PIldB. SQ.FT. TOTAL:
Ffp become subject o the Worker's Compensation provisions of the labor Code,you most
� ; foMwiN comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
OCONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby hy athat them is a construction lending agency for the performance of
the work for whi,h,hia per mit is i.suW(Sec.3097,Civ.C) TOTAL: FLECI'RIC FEE
lenders Name PLUMBING FEE
U Lenders Address QTiY, ' MECHANICAL PERMIT ,, PEE
1 reunify Nat I hove rand this application and state that the above information "t 'a' )
a. correct.l agree m crematories comply with all city and county ordnces and state lows reladng to PERMIT ISSUANCE .
t MECHANICAL FEE
F' building construction,and hereby authorire repmsenwivesofthiscity roenterupon the CONSTRUCTION TAX
U z ohne-mentioned properly for inspection purposes. ALTER OR ADD TO MECIi.
(We).,me m save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costsand expenses whichmay many way.ccrue against said City AIR HANDLING UNIT(TO I0,000 CFM)
in consequence of the ni Lit of this permie, (r eye,
(', _ Lf—wl ll AIR IIANDLINC UNIT(OVER 10.000 CFM)
4L
Situation,of Applicant/Contractor Data EXHAUST HOOD(W/DUCG PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,0(10 BTU) Date Recei p
Will the applicant or furore building occupmt store orrhandle hazardous material
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,1)(0 BTU) OI 1.:
Code,genion 2$532ppP
CI Yea ❑No VENTILATION IIAN(SINOI.E RESID)
Will the applicanrorfuwre building.ccupant useequipmem ardevica which man
BOILER-COMP(DHP OR 100000 BTU) ISSUANCE DATE
havrdous air rainstorms is defined by the Buy Area Air Quality Management BOILIlR-COME'(OVER IOO,WO BTU) p,
District? G
El Yes El No NEW RESID FOAL MECH.—SQ.FT. -4
ifth1 have read the houndnus rouratls ma to ements under Chapter 6.95 of the �p/1 `//`a`►�/�/��//
e uil ing do& of etycur entde.Sections 75505,25533 add 25534. I undersotif that
IfNeWiloftheresnmcuncndyhave
must ere,priormyssuanceofitytonficateof ken'f �2 X99
occupant of the requirements which must be met prior to issuance of a Certificate of V Ludt;�)���{�
y the
occupancy. h
Owner or amhmizcd.gem Data TOTAL: ISSUED BY
OFFICE
m 1