26540 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO B LD1 .-h.i Hf�l AI. PERMIT NO.
APPLICATION/PERMIT PLUMB Z;-MECHANICAL. n 6 C /1 O
BUILDING DIVISION BIIILI11NV HUM ECT IDENTIFICATION G v J(•�
Ii1J DINGAD`DRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
���! LwYa UNIT# LOTH
O NAF cNO: —110
1 :5&Ail
=
N/C CONTROL#
RCH ECT/FNGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
G l.F PLUM L'
PERMIT ISSUANCE;
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
I hereb ffimi that lam licensedunder
poZ ye provisinnsof Chapmr9(commrncingwith JOBDES IPTION
WrWO Section 10m1 o"f �i,i fthe Rosiness enJ Profasio 2 ,enJ my littnu is in PANELS
yU� full force and�wecbe .���
1- IUPtotrnsc Class Con�r4cmr Lie. l �_ 2f11TOI Bad AMPS
Z8yZ ARCHITECI-S DECLARATION OVER IOOOAMPS SQtJ'I�FLOOR AREA�O S/SQ.PI'.
OZ^G l understsndmy plans shop be used as publicrccords, W ��
ro,F SIGNS ELECTRICAL' �./ 6
Q� licensed Professional 11996 CC OWNER-BUILDER DECLARATION SPECIAL CIRCULI'/MISC/ �/j-I s+ 6
KO c, I hereby affirm that 1 am exempt from the Contractor's License Law for the
LL13LLun following re con.Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE.INST.
t'�-C2 5 which requires a permit to concoct,alter,improve,demolish,of repair any atrvctum v y/tI U
KE�� prior its issuance,also reclaims the applicant for such permitto file a signed,amemem POWER DEVICES
W W G p that he is licensed pursuant m the provisions of the Contractor's License Law(Chapter
d4M 9(commencing with Section 1000)of Division 3 oflhe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
)yX_y or that he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTl1RPS /G
tis4 Section 7031.5 by any applicant for a permit subjects the applicant los civil penalty of -a/ O Oct,p nm mom than live hundred doSFT.
llars($($500). NEWRESIDFNTIALELEC(R .
m ❑ 1,asnwncrnfthepmperty,ormyemploy¢s with wagesastheiramlecompemsation, Q STORIES TYPECONSTRUCfION
y will dome work,and the structure is not intended oroffered mrsale(Sec.11H4,Business
and Professions Code:The Controsam's License Law does not apply to an owner of
property who buildsorimproves therenn,and whodoes such work ldmselforthroughhis OCC.GROUP RILS.UNITS
wnemployees,Provided that suchimpromments arenot imendedoroffered fmasle.IL
however.the buildingor improvement is sold within mne yearef completion,theowner 'I O
builder will have the burden of proving that he did not build or improve fm purpose of
sale.).
❑ 1,asownerofthepmEn y.amexclusivdyconr ingwithlianaulcontmtonm QTY. PLUMBING PERMIT FEE FLOODZONE APN
construct the project(Sec.1D44,Business and Professions Code.)The Contractors PERMIT ISSUANCE
License Lawdmes not aMlyman ownerofpropery whobuildsorimprovesommon,and
whocontmasfor such projects with acontmcmr(s)licensed pursuant tothe Conuacmes
License Low. ALTI?R-DRAIN&VENT-WATER(PA) FEE SUMMARY
❑ I am exempt under Sec. ,D&P C fm this rearm BACK FLOW PROTECT.DEVICE l
SANITARY Y
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPI'p
WORKMAN COMPFNSA'fION DF.CLARA'1'ION SCHOOLTAX YN
I mousy affirm that l have a certificate ofccasent to self-insure,or a certificate of FIXTURES-PER TRAP RECFffT#
m1ms'Cmmpercimimn Immoncamr acerb fed co ytheremf Sec.380QI.a1,CJwhich Ask PARK FIE Y N
raven till employee's under this aGAS-LA.SYSTEM-1 INC.4 DUTI.HT$ RECTIP1'It
Policy# — `�� ' BUILOINGD 1. PS
C° Pant GAS-EA.SYSI RM-OVER 4(EA) PLANCHECK FEE
re"iOed copy is hereby famish
r
fCmified copy is filed with the city inspactimn division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING PER
CER'rIFICATR OF FAEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURAN
IThis ecetimn neeJ nmbecompRmd if the permit' mune hundred dollars($10) SEWER-SANITARY-STORM FA.200FT. ENERGY FIE
orlessJ
I cenify that in thep,rfomos fthewo�,uwhich Issisxued,l shall WATER HEATER W/VENT/ELECM
not employ any person in any mon sogvrI m the Workers' PAID
Compensation Lawsof Colifo ia. rate WATER SYSTEM/IRRYUNGt Receipt#
Q z Applicant
z O NOTICE TOAPPLICANT:If.afrer i ificateof Exemption,youshould NEWRESIDENTIALPI.MB. SQ.FT. TO L
L,0 become subject to the Warker's C lwneauon Frock ofthe Labor Code,you must
a1 forthwith comply with such provivons°phis permit she deemed revoked. BUIL '111 �—
0. [� CONSTRUCTION LPNDINGAGENC SEISMICFEE
Uz (hereby afErm thanh,rc is.cnnsvuclinn lending ngcncy for the perfnrmanca of
O the work for which this pe crit is issued(Sec.3091,Civ.C.) TOTAL: ELECI'RIC FE
IL Lenders Nam,
O [ Lende'a Address QI'Y, MECHANICAI,PERMIT FEE PLUMBINJ FEF.
IJa 1 cenify that I have mad this application and state that the above information is MECHANI ;E
0. cert l agree to comply with all city and county ordinances and slam laws relating to PERMIT ISSUANCE
rA building construction,and hereby authorize representatives ofthiscity to enteruponthe CONSTRUCTIONT
U z above-mentioned property fm inspection purposes. ALTAR OR ADD TO MECIL
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabiloies,judgmems,costs and eapetnes which may in any ways sec against said City AIR HANDLING UNIT IO,OIX)CPM)
ia,oul6d the Randall of this permit.
8 y AIR HANDLING UNIT(OVER 10,000 CFM)
Z J
SiKn[am of ApplicnnUCmm cm ate EXHAUST HOOD(W/DUCT) PAID
IIALARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date In,#
Will the applicant or future building occupant stem or handle haaurdous materiel HEATING UNII'(OVI?R IM."BTU) TOTAL:
us defined by the Cupertino Municipal Code,Chapter 9.12,and the Ilealth and Safety
Code,Section 23512(a)'f
0Yes a�,-s/No VENTILATION PAN(SINGLE RESID)
Will the applicant rfutumbuilding,capant uxequipmemordeviceawhichemit
BOILER-COMP 0HP OR 100,000 BTU) ISSUANCE DATE
�heonduus air contaminants as donned by the Boy Arc.Air Quality Management BOILER-COMP(OVER 100,00)BTG)
OisWctT ,.#
11Yes .gyp Nn NEW RESIDENTIAL MECIL SQ.Pf.
I have read the hmnrdous materials requirements under Chapter 6.95 of the
California Health&Soft',Code,Sections 25505,25533 and 25534, I understand that
If the building dos not currently have a tenant,that it is my responsibility m notify the
occupant mf the requirements which must he met pnor to issuance of a Cerificum of
Occupancy.
Owner or authorized agent Data ISSUED BY:
OFFICE /