26400 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO x D.BIFGC•ELECI'HI AI. PERMITNO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL 26400
IIUILDING PROJECT WENT IFICA'I']ON
BUILDING ADDRESS: SANITARY NO. (APPLKXI]ON SUBMITTAL DATE
•
10 , rAkNoi i UNITII LOT
OW .13S NAME: MINE: (UPItSACLIC NO:
. 9 A Wed%, /VAiCT •J
islij I&O N/CCONTROL#
, RCI PECI'/IiNGINEER: LIC NO: ADDY�i.S:
zo Be w I i a,Ia LN, Se c e 1:1
CONTACT: PHONE:
QTY. ELECTRIC PERMIT PEE BUILDING PERMIT INFO
Bj.DCi ELECT P40" M' I
PI3RMIT'ISSUANCE �' (ikL.x('
ni
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESC ION
QWz Iherebyaffirm Natlamlicenudunderprovisiomofaapter9(commencingwith
OF
x100 Section 7")of Division 3 of the Business and Professions Cade,and my licerue is in PANELS A
W fu 11 force end effect. Yyf•�aJJ~/��. � �yI� �,a..�
1<,y Licrnse C,le�ss� /�7 Lic.sl 5711 (r0 2( T02in AMPS g OT VT
F'% Dote_(1,p ]!Contractor Mft. 2( inIt ) I �, I Varma ��-
r , ARCHITECTS DECLARATION SQ.IT.FLOOR AREA S/SQ.IT'.
ZO y0�❑❑ 1 understand my plans.hall be used as Public records. OVER I AM �-1 t� 1, -
P'l-xt SIGNS EL I ALl 1�
W Licensed Professional
, OWNER-BUILDER DECLARATION SPECIALC CUI
UIIS .
�Lp�440,U I hereby affirm Ihm I an exempt invariant,Comracmr's License Low further
y7'`pfollowing rcuson,(Section]03L5,Business sort Professions Cole:Any city or county TEMP.METE4MiV&INST. J
p-J O a J which requires a permit to construct,alter,improve,demolish,or repair my struemrt _P
}� priorm in issuance,also requires the applicant for such permit to rile aaigned atammem POW DEVICES
K
<0 for he is licensed pursuant to the provisic of the Commit License Law(Chapter
a$�LL 9(commencing with Section 7")of Division 3 of Ne Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
,may or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS,Section]031.5 by any up,lteam fora permit subjects they, v civil penahy of
not more than Ove handled dollars.(851%1).
i , NEWRESIDETIALELFPI -SQ.FT.C3
STORIES TYPECONSTRUC'ION
will
do the work,andthestrucwrt is not intended oroffcrrN forsale(Sm.]044,Bus
and Professions Code:The Commcusex License Law does not apply m an owner M
properly who builds orimproves Thereon,and who dies such work himself er through his
employee.,prnviJedtM1m eucM1impmvemrnle
b.If, OCC.GROUP RES.UNITS
however,the huildingor improvemem is sold within one year ofcnmpletion,the owner- T �.
builder will have the burden of proving that he did not build or improve for purpoee of
sale.).
❑ I,as ownerofthe properly,amexclusively scumming with licensed references to QTY. PLUMBING PERMIT FEE FLOOD ONE APN
nsuun the project(Sec.](144,Business and Professions Cole-)The Conlrvcmle
License Lowdnes not apply to an ownerofpropcoy who builds orimproves thereon,and PERMITISSUANCE
whocommete for such Projects with a courtrooms)licensed pursuant o the Cantracter'a ALTIiR-DRAIN&VENT-WATER
License Low. (EA) PEE SUMMARY
❑ 1 em excmp under Sec. ,B&P C for Nis reason
SIDE
BACK FLOW PROTIfCf.DEVICE SANITARY Y N
Owner Dam RECEIFI'll
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,GOND, SCHOOLTAX Y N
❑ IM1erehy ul'firm thntlhave ucenifcnm ofamsen,msdf-insnm,ora cenificme of RECEIPTp
Workere'Compensatinn Insurance ora ceni0ed copy thereof(Sec.7g(kT,Leb C.)which HXTURES-PER TRAP PARK FEE V N
covers all employer's under his permit GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPTg
Policy N BUILDING DIVISION FE6.4
Company GAS-EA.SYSTEM-OVER 4 TA) PLANCBECK HE
❑ Certified copy is hereby famished.
&-Cenificd copy is Ned wish the city inspection divisum, GRBASIWNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERnmCATEOFEXEMPHON FROM WORKERS' GREASETRAP SOIT.S HE
COMPENSATION INSURANCE
(This section rommt be completed ifthe parody is fmome hundred!dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY HE
orleas.)
I certify that in the performance of the work for which this panni,is issued,I shall WATER HEATER W/VENTILILECTR
no,employ my person in any manner so nes to become subject a the Worsen' PAID
Z Compensation Lawsof California. Date WATI7R SYSTEWIRP.ATINGm Rete'
Applicant Z 0 NOTICE 1.0APPLICANT:If.after making this Cenificale of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TTA
TRI becomesuhjecl m en the Worker's Compensation provisionsofthe LebCode,you muss
k.
forthwith comply with such provisions orchis pemti,shut[be,deemed resulted. 4CjlLDINkHE
0. [� CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z Thereby air=tat in=is a construction lending agency for the performance of TA ELECTRIC
L) Q the work far which this permit is issued(See 309],Civ.C.)
lenders Name
V.
U Lmdefa Address Q'I'Y, MECIIANICALPERMIT PEP, PLUMBI GFEF. ��
a I cemly that 1 have read Ins application unit state that the ubove information is
aortae,. lugrea to comply with all city sand county ordinances and nate lows relating to PERMIT ISSUANCE MECHAN ALFEE ^�
F-' building constructions and hemby emhotive rtprtsemutives ofthis city literacy upon the CONSTRU ON TA%
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECIL
(We)agree to save,indemnify and kap hamtless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City AIR II ANGLING UNIT(TO 10."CFM)
inconsequence of egos r hi t.
`Y/T y` 5-_ Ipwq.l AIR HANDLING UNIT(OVER 10,000 CFM)
Signewre of ApplicmUCommcmr Data EXHAUST HOOD(W/I3UCH
PAID
HAZARDOUS MATERIALS DISCLOSURE HHATING (X1
UNIT 1 ,(1011 BTU) Dam ReceiplN
Will theupPlicml or Imam building mcumart,oe or handle harsomas amidst HEATING UNIT(OVER IW,000 B'N7 TOTAL:
as defined by,he Cupcnino Municipal Cade,Chapter 9.12,and the health and Safety
Cade,Section 25532(ep VENTILATION PAN(SINGLE REBID) is
❑Yes ❑No
Will IhcepPlicanmrfumrt buildingoccupam useequipmenmrdeviccswhich emir
BOILER-COMP(HIP OR 1(10,000 BTU) ISSUANCE DATE
hazardous air conmminams its dcOned by the tiny Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
istrict7 R1
❑Yes ❑No NEW RPSIDENTIAI.MECH.-SQ,FT. B/
I have mad the harardom materials re,dremems track,Chapter 6.95 of the
California health&Safety GNe.Sections 25505.25533 and 25534.1 understand that
if the building does not court buve a moan that it is my respomibility m notify Na V
occupant of the requirements which must be met prior to issuance of u Certificate of 1
Occupancy.
n� I
Owner or authorized.gem Date L: ISSUED BW. V
OFFICE