26393 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BDB:D1hT.-EI,HLTRTCA- PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL L6 `Q3
BUILDING PROJECT 10HNTIFICA'I'ION
V V V
BUILDING RLSS: / / SANITARY NO. APPLICATION SUBMITTAL DATE
//J 1/•//�-"//�/,/Ls UNIT# LOT
OW ERS NAME: PHONE: CONT CT R'g AM �_{](:Nrr],Q
T/' N/C CONT��,ROLp
ANCt11TECl'/ENGINEER: LIC NO: AD - /❑ `�
CONTACT': PHONE: o BUILDING PERMIT INFO
QTV. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ryZ I hereby affirm that l am licensed underprovisionsofChapter9(commencing with
WdEC gection7DpB)of Division3 of the Nosiness mff�eions Cade,and mylicense is in PANELS
��U full force effect. Q(s8
FZW Lice c.N UP T0200 AMPS
y<y I Canwcmr MI-1000)AMPS
Z O.yCIIITECTS DECI. R ION R1000 AMPS SQ.IT.FLOOR ARBA
OZ^q
I it
my plans shall he used as public records.
F'rnfee"3W SIGNS ELECTRICAL
eey2 Licensed Professional
y�C6 OWNP.R.BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
�C O a G I hereby affirm that I are exempt from the Commences License Law for the
01+1 :Wc following Mason.(Section 7031.5,Business and Profusions Cade:Any city or county TEMP,METER OR POLE INST.
O which requires a permit to construct,alter,improve,demolish,or repair any structure
N� prim to its issuance,also requires the applicant fersuch permirto Ole o signed summoner POWER DEVICES
W qO that he is licensed pursuant to the provisions ofthe&ntrachora Licence,Low(Chapter
9(commencing with Section 70110)of Division 3 ofthe Business and Pmreuians Cade) SWIMMING POOL ELECTRIC ,,a// VALUATI1K
y_y onhat he is exempt NerefromanJ@e basisfonhe alleged exemption,Any viohtion of sem'
I—. �• Section 7031.5 by any applicant rm
fora peit subjacts the i pplici nno a civil penalty of OUTLETS-SWITCHES-FIXTURES �s+ t
mom Nun five hundred dollar.($5W).
a, A NEW RBSIDENTIAL ELECfR _SQ.PT. STORIES TYPECONSTRUCTION
W ❑ othe)wrk,of thepmpucture myemployedorofwed forstheirule atmpereodoa,
a will clothe work,ands: oCmarsnotimendeaorafwdoes not it(Sec.7044,Business
arta Professions Cade:The Cnnt.ctoes License does
does not apply N on owner is /- 1
own errywyees,fdsorimprovesthimpareand whoaacsauchande Nmselfm tluoughhis 1
RES.UNITS
emr,the
heailding or improvement
vel impmvemcrosam oat earofdmolfered forevear. '� I dd
however,iHhave the
burden of
issordwithin one year orcprove on.far purpose
I TOT ��• ��„ SII R
builder will have the burden of proving that he did not build or improve far purpose of d' t u
sam.)' QTY, PLUMBING PERMIT s•1' APN
❑
as the project
Business andly contracting with licensed Ile
Cometon to , f '
aneuun dm pmjat(gee. aro Business and Professions Code:)ova Croven,and PERMIT ISSUANCE
Grenu lawaoes not epplytoennwntto1propeny whobuilJswimproveatherewt,end - _
whomntncmfor such prejecis with aconwctorho licensed pursuan0o the Comrnaoea ALTER-DRAIN&VENT-WATER(FA)
License Law. FEE SUMMARY
❑ 1 tun exempt under See. ,B&P C for this reason BACK FLOW PROTECT,DRVICC •ANITARY O TY_N
Owner _Dune RECRIPTa
DRAINS-FLOOR,ROOF,AREA,GOND.
WORKMANCOMPENSATION DECLARATION SCHOOLTAX YN
ereby.!thn 1 have a cenificane of canon m self-inane.m s c.rtif'ma of RECEIPT#
FlXTURES-PER TRAP
Workeli Cmmloyzeionlnsu.ncearettrtified copy thereo((SreJg00,labCJwhich PARK FEE Y N
coven dl employee'sm r / OAS-EA.SYSTEM-1 INC,4 OUTLET'S BUILDING DIVISION FEES
Policy#
Company - ' < a GAS-EA.SYSTEM-OVER 4(IA) PLANCHECK FEE
❑ Certif'� mllfi
wed copy is filed with the city inspection division. GREASFIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION PROM WORKERS' GREASETRAP SOILS PER
COMPENSATION INSURANCE
(This section neWnotbe completed ifthe permit is fortune hundred delta.($]W) SEWER-SANITARY-STORM P.A.20017. ENERGY PEE
or ins.)
I certify that in the ofarmwce.fthe.,kfor which this permit is issued,l shell WATER HEATER W/VENT/ELECR
net employ any prevent in any manner sa u m became subject to the Workers' PAID
Z Comw
peationlawsof Gdifomie Data WATER SYS'rB
EM/ EvDNG Dote Receipt
Applicant
z� C NOTICB TO APPLICANT:If,after making this Certifcale of Exemption,you should NEWRCSOINTIALPLMIL SQ,It. TOTAL: s
0)J become subject a the Worker's Compensation previsions ofthe lahm Code,you must
LLa^^ ; forthwith comply with such provisions or this permit shall be deemed revoked. "BUILDING PER
AW Q CONSTRUCTION LENDING AGENCY dWrSEISMIC ME /I)
U Z I herebyaffirm Bm
Ban the.is a cotruttien lenJingagency for the performance of S
O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC HE
lenders Numc
0Lender's Address Q'T'Y. MSCII IANICAL PERMIT FEE PLUMBING MH
r W 1 certify that 1 have Mail this application and into that the above information is MECHANICAL FEEcored.l agree to comply with all city and county ordinances and state laws reading to PERMIT ISSUANCE
F" V3 buildingconstruction,said hereby authorize upmuntadves ofthis eiryto enter upon the CONSTRUCTIONTAX
V above-mentiry
oned property for inspection puoaes. ALTER OR ADD TO MECH.
(We).,Me to save,indemnify.nd keep Int sea the City of Cupertino against
liabilities,judgments,costs and expenece which ay in any wayaccrue against said City AIR HANDLING UNIT(TO 10.000 CPM)
in consequence of the g.nting f thi unit.
AIR HANDLING UNIT(OVER 10.000 CFM)
Signature of Applicant/Conuecmr Dal. CXHAUSTHOOD OV/DUCT) PAID
HAZARDOU ATF.RIALS DISCLOSURE HEATING UNIT(TO 100,00011'LE) Data Receipt
Will the applicant or futur wilding occupam emrc or handle hazardous material BEATING UNIT(OVER 100,(NNI BTU) A
n defined by the Cupertino nicipal Code.Chapter 9.12.and the Health and gaiety
Code,Section 25532(e)1
❑yea ❑No VENTILATION PAN(SINGLE RESIDE
Will the or future building occupant use equipment ordevicn which enter
BOILER-COME'(3HP OR IW,0W BTU) ISSUANCE DATE
,arardous air cmn.mirents as defined by the Bay Area Air Quality Manage reara BOILER-COMP(OVER 100,11(11)BTU)
iN et7 p�
❑ 0 N NEW RESIDEWIALMECH. SQ.PI'. - ff.4 B D
I It a read t hazardous materials requirements under Chapter 6.95 of the s���
Calif Ileal SaI
Sections 25505,25573 and 25574. Iunde.send that '1
i17f the ildiny- acs nothavenlr mo'thud,is my respansihilitymnotify the
ant.of the rcyhich must be me prior m issuance of a Certificate of is _
ney.
Owner aro ode Data TOTAL: ISSUED BY: /N
OFFICE