26284 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO NUILGiNI:-rLM l'RICAI. PFRMI'1'NO.
APPLICATION/PERMIT PLUMBING.MECHANICAL 26284
BUII.DING DIVISION BUILDING PROJECT IDEN"1'IFICATION'
BUILUING/�AADDR�ESS: A SANITARY NO. APPLICATION SUBMITTAL DATE:
160 W W O UNITp LOT#
ERS NAMEPHONE: CO LIC NO,
s NAC CONI ROL#
'ARCID: ENGINEER:
LIC NO: AD RE35: F-1
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Slo — BLDQ [LC YL M"CH
IZM PERMIT ISSUANCE y1T7�Y /r[y,.7{`
LICENSED CONTRACTOR'S TION APPLIANCES- ESIDENTIAL
OKZ Ihcmbyaffnrn that lam unrp
licensed deroviowsofChapter 9(commencing with JOB UISCRI%'ION
FICO Sutton 70010)of Division 3 of the Business and professions Code,and my license is in PANELS
ty F full have and effect. �-
LQ.,LtrJ UP T02 Licensc Class Lic.4 A `
rnQ°' Dam Comma VIII-I( M S
F yG_ ARCHI'IE—S DECLARATION 1 A SV.Ff.I'LOOR AREA S/SQ.%'.
L O'er+ I understand my plans shall a used as public records.
O'!.—O �OAk/C
st: "LECTRIC ANN
Qf,..I Licensed PmPossinnal
C y)WQ
OWNER-BUILDER DECLARATION 5 ECIALC CULT/MISC.
XOyO I hereby affirm that I am exempt from the Conrrackors License Law for the
W3ay following mason.(Section 00315,Business and Professions Code:Any city or county 'MP.METER OR mLE INST."
40j which requires a permit to construct,alter,improve,demolish,or repair any structure
�r�aF prior to its issuance.also requires the applicant for such permiuo file a signed smtement POWER DEVICES
W W< that he is licensed pursuant the provisions of the Contractors License Law(Chapter SWIMMING POOL ELECTRIC
G.a01' 9 lmmmenang with Section 9000)of Division 3 of the Businesa and Pmfeverms Code) a#��jVALUATION
,M, mmar he iscxempuhercftom and the husisforthe alleged exemption.Anyviolation of UTI FIS-SWITCHES- 2�J O�
Y Section 0031.56 applicant a permit subjects the applicant to a civil It f Les FIXTURES
J vV
F Z Q Y any aPP man lee Pena y e
$20 oat frommum rive hundred dollars($500p. NEW RESIDENHALELECTR _SQ.Ff. STORIES TYPE CONSTRUCTION
yFo ❑ I,asownerafinepropmy,ormyemployeeswithwagesasthcirsolccempeaation,
i3°= will do the work,and the strunurc is not intended or offered for safe(Sec.7044,Business
and Professions Code The Conmacmr s License Law does not apply to an owner of
property whobuildsorimprovesthereon,and whadoes such work himselfonhroughhis
employees.provided Nm sucM1improvcmcnts amnwt imm�dcdoroffcmd ferselc.11 � p OCCC.GROUP RES.UNITS
however,the buildingia improvement is sold within one year ofeampleti.e.theowner- 17 (,�A 1
builder will have the burden of prnving that he did not build or improve for purpose of f - u
sale')" QTY. PLUMBING PERMIT EE r \
❑ [,as ownerefthe property,amexclusivelY contracting with licensed conuacmrs to r I Iq.O UZONB�' f�a APN
construct the Praiser(Sec.0014,Business and Professions Calc:)'Me Coneracror's r b V 1 GI'.al
License law does not apply m an ownerofpmpeny whobuilds nrimprovesrheteon and PERMIT ISSUANCE
whocomucts for such projects with aaonuacmrts)licensed portion 1.he Conmacmrs ALTER-DRAIN&VENT-WATER(EA) Y
Licensc law.
❑ 1 em cncmpt under Scc. .B&P C far this rceson BACK FLOW PROTECT.DEVICE O glUi:FRHS
SANITARY Y—N
—
Owner Duke DRAINS-FLOOR,ROOF.ARG.COND. RECEIT#
WORKMAN COMI'I:NSA'HONDECLARATION SCHOOLTAX Y N
❑ Ibcreby affirm that l have a cenificane of consent to self-insum.m a uniGcate of )IIXTURE$-PER TRAP RECEI PI'#
Wmoars mpensation Insurance oracenifrd rnpy thereof(Sec.78W,Lah CJ which PARK FEE Y N
rsall employee's andenhis permit. Hf.CLI%#
ave
GAS-EA.SYSTEM-1 INCA OUTLETS BUILDING DIVISION FF
Policy#
CCad G (E
GAS- .SYSTEM OVER4A) PLANCHECK FEE
Cl 6
Certified copy is hereby famished.
I ❑ Certified copy is filed with the city inspection division. GRGSFJINDUSTRI.WASTE INTERCEPTOR GRADING FEE
CIiR3'IFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
('"is section need not a completed lithe permit is for one hundred dollars($100) SEWI2R-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify them the perfnrmnnceof rhe work for which this permit is issued,Ishall WATER HEATER WNENT/f:LECTR
not employ any person in any manner m as to became subject to the Workers" PAID
mt
Cournmion Lawsnf California. Date WATER SYSTI3M/1'REATING Date Re t#
O z Applicant
z 0 NOTICE I"O APPLICAN'f:If.after making this Cerificace of Exemption,you should NEW RES]DENTIAL PI.MB. SQ.Ff. TOTAL:
y become subject In the Worker's Compensation provisions ofthe Labor Code,you musk
forthwith comply wikhsuch provisions or this permit shall be deemed revoked. BUILDINGI
�t
(�
CONSTRUCTION LENDING AGENCY SF.I$ L
z I hereby alfirm that there is.f.marudion lending agency for the performance of ��
U Q the work for which this permit is issued(Sec.309],Civ.C.) O F.LE C F iia
Lenders Name PLUMBING I'EE �^
0 F Lenders Address QTY. MECHANICAL PERMIT FEE
U I mnify that I have read this appfearion and Wrote mat he wave mformatmm Is 41CMECIIANICAh FF,B
correct.I agree In comply with all city and county endurances an dinaml.7mlatiagto PERMIT ISSUANCE
E" building conswctien,end her emhodureprcsennowesof ria city to corer upon me CONSTRUCIIO -'A%
U rz verve-mentigifenpeny or ins Ginn puryoss. ALTER OR ADD TO MECN.
(We)agme ko save, nor in, and kap ha�Mes,the Ciry of Cupcnino against
lantudi^jad,pumas,coofland rimsas which may in any way accmcagdnstkaid City AIR HANDLING UNIT(7010,000CFM)
'• Fence of rhe g ing trait.
AIR HANDLING UNIT(OVER 10.000 CFM)
Si am n pPMNw ar name Date EXHAUST HOOD(W/DUC17
PAID
1- Date Rxa #
11 RDOUS MATIJilA1S DISCLOSURE HEATING UNIT IfX1.000 BTU)
Will he upplicam nrfumm building oecupwr sane or hvndle havrdous material HEATING UNIT(OVER 100.000 BTU) TOTAL:
as defied by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safe,,
Co,c,Section 25532(ap VENTILATION FAN(SINGLE RESID)
❑Ycs ❑No
ISSUANCE DATE
Will theappcontaminantscwtorfmumbuildin tunecryipmrn tordeviceswhichemir BOILER-COMP QHP OR 1110.(00 BTU)
lby by the
'aaanlous air contaminants;is Jefned the Bay Area Air Quality Management BOILER-COMP(OVER I(XI,tXNI BTU)
P Q O
J C3 Yes ❑No NEW RESIDENTIAL MECfI. SQ.%, erg
I have mad the wondrous materials requirements under Chapter 695 of rheill
California Heahh&Safe,,Cub,Sections un
25505.25533 and 25534. 1 derammd that W IU 8 11
te
if the building does not currently have a nam.that it is my responsibility to nntify the /�
wcupanr aide re luimmcals which must be mit ora Certificate to issuance orCertificate ter C1 f/'ry� /
o, r
Occupancy.
Owner or amhenN eagent Date TO ISSUED BY: //NQ
OFFICE.