26875 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOUn:mNfv..il"MRICAT. PERMH NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
-7 26875
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS. NTS
SANITARY NO. AI'PLI�CATIOI SUBMI TALDAM
00W1 Oat MTM _S LATH
O NF 110 CO ACTOR'SN LIC NO: V
LONA UNaRUE N/C CONTRO I
ARCHI ECT/ENGINE' LIC NO: ADDRESS:
34r Aq a cos gr os c
CONTACT': PHONE:
QTY. ELECTRIC PERMIT FEE DUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION p LIA - ES IAL JOB DhSLIUM'ION
❑CZ Ih700m lDi ihatl3 ofth Business
andirmficsoun,Club,
g wiN
Y100 Senior2(old0f'Divisinn3af the Business and Professions Cale,and my licenx is in pq IS
ttT�-LL full force nnA effect. 13 /� T.f 2 MP9
Q ZUz W License Class <J Lic.M (I /,J
y¢y �Contmcmr, 20 BOO AMP
z8�o` ARCHITECTS DECLARATION O R 1000 S SQ.Pf.FLW AREA 1/SQ.Ff.
O ❑ 1 understand my plans shall be used as public records.
r:. ; VVA SIGNS CTRICAL
Q�y -j Licensed Prnfessinnal
W TKWQ OWNER-BUILEBERDECLARATION SPECIALCIRCUIT/MISC.
X0 I hereby affirm that I am exempt(mm she Convector's Lima.law or he
m 3 LL y following rexam.(Section 20315,Business and Professions Code:My city cou ty TEMP.METER OR POLE INST.
F ON; which requires a permit to concoct,alcor,improve,demolish,or repair any w
pdono its issuance,also requires the applicant for such pemutto file a signed mt rot POWER DEVICES
9Wems'C O pursuant that he is licensed pursuano the provisions of the Contractor's License Law(Chapter
v'Ko�' 9(cammencing with Sectioolf")of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION O/^
WMo, or that he is exempt herefrom and she basis for the alleged exemption.Any violation ofETS- f
F G Section 2031.5 by any applicant for a Permit subjects the applicant to a civil penalty of SWITCHES-FlXTURES lQ� OOd
not mom than five hundred dollars SSOB.
❑ NEW RESIDENTIAL ELECTR -SQ,PT.
w ❑ I,uanwnensfinepropeny,ormyemployeeswiNweBesv meirmlecampenvsion. Q STORIES TYPL'CONSTRUMION
y .- willitalhe work,and the structure is not intended conflicted for sale(Sec. Business
and Profession.Code:The Cmtmetme,License Law does not apply to an owner of
property who builds or impmvea thereon,and wbodmes such work himselforthmughhis
employees,prnvidcdthutsuchimpmvementsmenotintendedormficm fbrswl .If, OCC.GROUP RES.UNITS
h wevogthe noldingor impnwemem is sold within oneycuofcompinion,Neowmer- 1:
builder will have the burden of proving that he did not build or improve for purpose of
s la),
❑ 1,as owncnmhepmamy,um exclusively contracting wilt liccionalmnvodore to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
Lnnswct the project(Sm.70N .Business and Professions Code:)The Cnnweme.
icense Law does not apply mannwnerofproperrywhobuilds m improvea dopa m.and PERMIT ISSUANCE /a
whocontmns fcosuch projects with aconvactoms)licensed puruantto the Contractor's ALTER-DRAIN&VENT-WATTiR(G)
Llceose Law, FEF-SUMMARY
❑ 1 an exempt under Sm. ,B&P C for this reason BACK FLOW PROTECT.DEVICH D
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA,CO RECEIPTM
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
�. Wo ma'ConafBmuhatlhrance ora mineofloose mmael(Sm.rt,orece C.))Which FIXTURES-PERMAP RF.CF:IPTp
m,marti Cnmpenvtioabsumaaorucmified copy Nmmf(Sm.3800,Lab CJ which PARK FF.E Y N
era al employee's under Chia permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT M
Policy BUILDING UIVISIObUM
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHF.CK FEE
❑ Cenificd ropy is hereby fumiahed.
❑ Cenifiedmpy is filed with the city inspection division. OREASE/INDUSTRL WASTE INTI?BCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE.TRAP SOILS FEE
COMPENSATION INSURANCE
('Imaam9iga amilmst be completed ifinepemut is forone hundred dollum($10m, SEWER-SANITARY-STORM EA.200IT. ENERGYFEC
or less.)
I cenify that in the ado era of the work rat moli Nispemhitisisaued.lshull WATER HEATER W/VENT/ELECI'R
ooh ny any Pe m y memo so hero subject to me Workma PAID
C rnmLsu WATER SYSTEMITREATING
pensnion law nmie. Data .f/ Date Recciptp
z PPlicent �( ( «'sI�
z NOTICE TO APPLICANT:If,she,making Ms Certificate RESIDENTIAL PLMB. SQ.PT.ificate of Exemption,youshould TOTAL:
V) become subject to the Worker's Compensation provisions of the labor Code,you must
? forthwith comply with such provisions m this permit shall be deemed revoked. BUILDING FEE
aQ CONSTRUCTION LENDING AGENCY SEISMIC FCC I�
1 herby affirm in., hem is a concoction leading agency for the performance of
V O Al. ELECTRIC FEC
the work for which this permit is issued(Stu.3097,Civ.CJ
Isnder's Name
0 F Lender'.Address QTY, MECHANICALPERMIT FEE PLUMBING FEE `
L) 1 cenify that I have mad this application and state mat the above information is
4>a correct.I u9me to comply with all city and county ordinances and state laws mlating to PERMIT ISSUANCE ' MECf1ANICAI.PEE l�
building mntemmhim,mid hereby auNmile representativesof Nis city to enter upon the CONSTRUCTION TAX
U abim
no,ca,for miection puryoses. ALTER OR ADD TO MECH.
x mdy xrd kmp hr . the City of CUPcninn against
lius su m,criaeswhich y any. ecow.g.m.t.uid City AIR HANDLING UNIT(I'010,000 CFM)
irh rr ngof Ni.pecoi
/ AIR HANDLING UNIT(OVER IO,IXIO CUM)) �
Sigcant/Cnncocmr lam EXHAUST HOOD(W/DUCD �
D
HAZARDOUS MATERIALSDISCLOSURE HEATING UNIT ITO 100,00X1 BTU) Data Receipt If
Will the applicant or future building occupant same or handle harvdaus material HEATING UNIT(OVER 1(10,(NNI BTU) TOTAL:
v defined by the Cupcnino Municipal Code,Chapter 9.12.and the Health and Safety
Cede.Smllmn 25532(81 V ENTILATION PAN(. BRISID)
ClYcs ❑No
Will the applicant m(mart building occupant ace,equipment or devices which emit
BOILER-COMP(31IF RIOII,g)OH ISSUANCE DATE
huuNou,air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVE 100.00 BTU) 0 p
District? 1W
ID Yea 13No NEW RESIDENTIAL MR H. Q.R. u
I have mad the hmurdom materials requirements under Chapter 6.95 of the
California llcxlth&Sal'cry Cmle,Sections 25505,25533 anJ 25534. Iundemandthal
otheanilJi ngdeco nomcurrently Imveast he et itis myssuance oft,
1onmmiry the y
Oloop
occupant of the rcyuirumanms which must he mem prior m issuance of n Cenificum of Cl/1 I.)Y
Occupmmy. kr'
Owner or authori cod agent Date TO ISSUED BY:
0