26156 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOL -n TRI AL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 26156
BUILDING PROJECT IDENTIF'ICA'TION
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMTGLDATE
O S-; . C PaSS UNIT# LOT#
OWNERS NAME:A/h haVC(4k �P1b E: 30- CO�AOCAL NAME: LO NIC CNTROLp
ML
RCHITE GINEER: LICNO: A_QpKESS: /1 El'e.LOct5, JVtk-,tjL S) -7 10
ONTACl:PHONE: BUILDING PERMIT INFO
7QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MCCH
It
PERMIT ISSUANCE
1-1
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL
I hereby affirm that l am licensed under faa s 9(commenein with �s ..[ JOB D[SCRIPDON
O 0 Ye ptovisioneo per a J'�
14100 Stttion]OOIB ofDivision3ofthe But*/p�a.ss end ProfeuiomC liend my license isin PANELS
Fye+bI C fall farce not effect/ f -.3 i �o o v
6ZIn License Clan UPT02IXIAMPS �2S Wa4�. Heo Ter
6a pato Cantmcmr 201.1000 AMPS
FyZ ARCHITECTS DECLARATION SQ.FT.FLOOR AREA S/SQ.FT.
ZOO,— lunderstandm shall be used blit records. - OVER 1000 AMPS
OZ^O my public
�H(=JSIGNS ELECTRICAL
4 � Licensed Professional
6
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
°xiOaU I hereby affirm Net 1 L exempt from the Contrecs License law for Ne
Ia13 wFi following rcuson(Section]0331.5n Code:Business and Professions Any city ter county TEMP.MEIER O0.POLE INST.
which requires a Permit to wmtrai alter,improve,demolish,or repay any structure
�n prior m its issuance,also requires the applicant for such permit torte a signed smmmm
ePOWER DEVICES
aQ O that u licensed pursuant n the provision of the Contractors License Law(Chapter
❑y FlECIRIC e 9(commencing with Section]0( Division laf theBminese and Professions Code) SWIMMING POOL VALUATION
_y mNm he is cacmpnhcrefrom and Ne bmis for the alleged exemption.Any violation of ^ Q a
OUTLETS-SWITCHES-FIXTURES
� aly
>
Section 7031.5 by any epplicaapplicantfore permit subjects dm epplicantto.civil'nal".1' 0 -�
Q nm more than five hundred dollars(S5W).
. O NEW RESIDENTIAL ELELTR _SQ.PT. STORIES TYPE CONSI'RUCI'ION
K m ❑ Lmowne.and thromeam,imyempindedinthwalforssheirwle 744,Business
y will Jathe work,ands TheCureanotln¢nJese La a does not
to M Business
and Professions Code:The..a mor ma,and
Lew Jou not apply f an owner of
pomnywbmtprovidmph....Nerwn,AndwM1"Jassuch wnrkhimaelforthrough his OCC.GROUP RFS. NITS
cmployas,provided prove improvemcntthin me earofc mpletiad torula.If,
however,shebcetie brimofprovinisut he
not build oimprove for thepose of TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,mawnerofthepropeny.amexdusivcly contracting with licensed contractors to QTY, PLUMBING PERMIT FEE FLDOD ZONE "N
construct the pmjmt(SIN.7044,Business end Professions Code)The Contractors PERMIT ISSUANCE
License Law does not applym an ownerof proper whobuilds ar impmveathonaim and
whucmnracv fmsuch projecu with acodramormi)Iicamed parsuanuoshe Cinummrs se Law.
License
ALTER-DRAIN@VENT-WATER(EA FEE SUMMARY
❑ l wn exempt under Sec. ,B @ P C for this mission, BACK FLOW PROTECT.DEVICEai, le _=179517M
SANITARY Y_N
Ow ny Date— DRAINS-FLOOR,ROOF AREA,COND. RECEfPI'p
/ WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
(d ers'Coyaffumth Insum einaceniofcanentbof(Smure,nr Lab C.))wiche of FlX'NRES-PER TRAP RECEfPfp
Worken'Cnmpensvtion lmumnce macenified copy therca((Sec.381p,Lab CJ which PARK FEE Y N
Cover.Jl e"I sal:" ]ratECEIPT#
Policy C: 7 (/ GAS INC.INC40I1TLET5 BUILDING DIVISION MES
Company >�a .F9f "-B, t" GAS-EA.SYSTULOVER 4(EA)AftLANCI{ECK FEB
❑ Candied copy is hereby fumished.
Candied copy is filed with the city inspection division. GREASEIINDUSTRL WASTE INTERCEPTOR RADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP O E
COMPENSATION INSURANCE
(This section nod not be completed ifthe Permit is fours hundred dollars($100) SEWER-SANITARY-STORM EA.2o0FT. PYERGY FEE
mlew.)
I cenify shvsinhe perfomwnce of Ne work forwhich this penitis isissued,Ishall WATER HEATER W/VENT/ELELTR
not employ any person any manner w as to become subject to the Workers' PAID
z Compensation Laws of Califomia. Date WATER SYSTEMiTREATING Data Receipt
Applicant
ZOZ0 NOTICETO APPLICANT:IL after making this Cenificam of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
!-' become subject o the Worker's Compensation provisions of the Labor Code,you must BUILDING FEE
Fri > forthwith comply with such provisions or this permit shall be domed revoked.
6W. M CONSTRUCTION LENDING AGENCY SEISMIC PEE
1 hereby Affirm that is a construction lending agency for the performance of
Z. TOTAL: FlECI'RIC FEE
U
O the work for which this permit is issued(Sec.7097,Civ.CJ
Laii Name PLUMBING FEE
finder's Address QTY. MECHANICAL PERMIT FEE
U I cenify that 1 have mad this application and state that the above information is MECHANICAL FEE
wreot.lAgra m comply withnll cilyandwuntyoNimmeas end nem lawsrelmarig to PERMIT ISSUANCE
buildingconwcdon,and hereby ouNorissrepmunutivesofthiscily menterupon me CONSTRUCTION TAX
U 'Z above-mentioned properly for inspection purposes. ALTER OR ADD TO MECIL
(We)agma to save,indemnify and kap hardness the City of Cupertino agulnst
liubilities,judgmeots,cosu Andexpcnus which may in any way acne against said City AIR HANDLING UNIT OU 10,000 CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10.000 CFM)
Signature of ApplicanUConsmcsor Data EXHAUST HOOD DVIDUC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO Ulf.00 BTU) Dam Based"#
Will the applicant or future building occupant store Or handle hactrdous material HEATING UNIT(OVER IW,(gO BTU) TOTAL
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Coda Sectio"25532(apl
11 Yet; CCN—. VENTILATION PAN(SINGLE REBID)
ISSUANCE DATE
Will the applicant orfuumbuildingocupunl useni,ipme"tmdevices which emit BOILER-COMP(JHPOR 100,000BTU)
shamNous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100.100 BTU) P A 6 D
Dn rin1
❑Yes '&--N NEW RGSIDENTIAI.MECH. SQ.FT. {IfI n/
I have read the harardous mwen"Is requiremenu undo,Chapter 6.95 of the MAY ^5 1994
California Berlin @ Safety Code,Sections 25505,25533 and 25534, 1 understand that
if the building does not currently have a tenant,that it is my responsibility to notify Ne N
scup M the ms which muse be met prior to isauana of a Comma.of I 1 T OF yLIPEf1 I H r V a
5=/8=9#
Owner or midamivd agent Dam - TOTAL: ISSUED BY
OFFICE