26007 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BDLDINGCFTEUTRTEA. PERMIT NO.
APPLICATION/PERMIT PLUMBING-MF.CHAN[CAI• O O O 1
BUILDING DIVISION BUILDING PROJECTIDE HFICA'I']ON
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
UNIT# LOTx —/ Z�
O N SNAME: PIIONE: CONTRACTOR'S NAME: LIC NO: `
Q L bJHq t I _V 3� NTC CONTROL M
ARCHIII`Q/PNGINF:ER: LIC NO: ADDRESS(:' ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
/
_ BLDG ELECT PLUMB MECH PERMIT ISSUANCE Ian ill Rl 14'S
LICENSED CONTRACTORSDECLARATION APPLIANCES-RESIDENTIAL (211 TOB DESCRIPTION
�y
pyZ (hereby affirm that l Am licensed under provisionsofC'hapter 9(commenciagwith
FOO Section 7"oof Division)of the liusincssand PtOfcealona Cede,and my license is in PANELS
FjWLhr force And
Licum Class Lic.N 3 ITP T03(XIAMPg 1L Ilan
Qy Date f-/ Contrectm ✓ 201-I001)AMPS
FO,z ARCHHEM'SDIiCLARALON OVER 1000 AMPS SQ.FT.FLUOR AREA SISQ.FT.
I understand my plans shall At used as Public miords.
G H F W SIGNS ELECTRICAL
6yf,�a Licensed Professional
N,Xd OWNER-HUILDER DECLARATION SPECIAL CBRCUTOMISC.
KOiF 1 hereby Affirm that 1 am exempt from the Crnvracmr's License Law for the
W 3 O y following rcmon.(Sesda m 7031.5.But..,and Professions Code:Any city m county 9EMP.METER OR FOIE INST.
I-:- J which requires a penial to consortia.alter,improve,demolish,or repair Any ntrucWre
5_WY$ prior to its iasuunce.also rquims the applicant for such Permit o file a signed natemem POWER DEVICES
�a<0 that he is licensed pucsuuntto the provisions of the Contractor's License law(Chanar
cap, C 9(commencin wish Station 7(C fDivision J ofthe Business and Professions Code SWIMMING POOL ELECTRIC
Kos (commencing )o ) VALUATIQND
m_w Se Htmhcisucempinytherefrom And the basisis theallegedexemption,
Any violadlytif "OUTLETS-SWITCHES-FI%TURES D /,•lO CCJJ
F>G stttion]031 5 by anY Applicant for a pmnit subjects the Applicant to•civil icmhy of + V
$�C of mom than five hundred dollars 4500). NEW RESIDENTIAL ELECR —SQ,FT.
1'I�p n❑ 1,aaowncrofthepmperty,o,myempoyccswilh wagesmlheirsmlecompensution, S'1 ORAS TYPE CONSTRUCTION
=2 will do the work,and the someone is not imamledoroffems!for Al7044,Business
and Professions Code:The Contractor's License Law dues not apply nt an owner of
property whubuiIdamimpmveathereon,and whodoes such workhio ielfm Nmugh his
.warrapoye intpmven¢ms arc not iamadedraeffered fo.Me.If, OCC.GROUP RES.UNI'T'S
howcvegthe buildingorimpruvcmenl is sold widrinoneynr.fcomNAha.the owner- TO'T'AL:
builder will have the buNcn of proving that he did not build or improve for purpose of
sale.).
❑ L as owacrof the proper ,Ancxclusivelycomracting with licensed contractors An QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.In".Business and Professions Code)The Contracmr's
AndPERMIT ISSUANCE _l'
LiamcTaw d«snot apply m un owner of pmlcnY who builds a impmvo thereon
whocontmctsfor such pmjectx with a conlructot(s)licensed pursuant to the Coaoa,lor'a ALTER FA FEC SUMMARY
License Law. l� )
❑ 1 con exempt under Sec. ,B&1'C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Date DRAINS-FLOOR.ROOF,AREA,CONO RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL(AS Y N
❑ I hemby infirm that l have a certificate of consent to oracenifiureofFIXTURES-PER TRAP `� RECEIIT0
Worked Compensation lasummeemiternified copytheoxxQSa.3800,Lab C.)which PARK PER Y N
_ c.vers.11 employees under thin pemtil. RfiCEIfTx
Policy or 7-2n 1P1' GAS-EA.SYSTEM-]INC.40ITILEIS
BUI D.G IVIMON FEES
Cmnp�s, Cats GAS-EA.SYSTEM-OVER 4(FA) e� —t I'.pL ,CUP
CI( -1Y1'EE
L�Ccnified copy is filedified copy is hwith Ne e�inspection division. GREASEINDUSTRI.WAS HE INTERCEPT I
- t l u�l R UI G Ali
CERTIFICATE OF EXEMPTION(ROM WORKERS' GREASE FRAP �.�Y
COMPENSATION INSURANCE
Misuaimnadnntlscomple difthepermitisforonehundruldollan(Slip) SEWER-SANITARY-STORM EA.2 IIT.
or ins.)
I certifythr Otte sernrmance ofthe work far which this permit is issued,I shall WATER BEATER W/VENTIE.LECIR
not employ any person in any manner so As to become subject to the Workers' PAID
Compensmionl-aw+of Califomia. Date WATER SYSTHM/IRE/TING Date Receipt#
Applicant
O O NOTICE TO APPLICANT If,after making this Cenificam of Exemption,
'z rr you.you mule NEW NESIDEM'IAf.('LMH. SQ.FT. TOTAL:
^F VI btaomambjtauothe such
Calm,crisis Provisions of deemed
Code.you man
a ? fonhwitb nnmply with auchpmvisians onhia Pertniuhall be JeemN revoked. BUILDING FEE � _p0
0. G] CONSTRUCTION LENDING AGENCY SEISMIC FEF, f by
:D Z 1 hereby affirm that them is a construction lending agency for the performance.!
U O the work lot which this permit is issued(Sec.3097.Civ.C.) TOTAL: �-C [LF.CIRIC FEL
lender's Nome
O U Iamler's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I certify th:a 1 have read this application and state that the alone information is
counter.I agree to comply with O city and county oNLnancennd state laws relating to PERMIT ISSUANCE � �j MECHANICAL FEE.
bullJloun
gmntction.and herchyautltomc repmnenciuseaa(thm O
io city enter upon the V CONSTRUCTION TAX
T..) Z abwcmerannd property for inspection puryoses. ALTER OR ADD TO MECH.
(We)agree on save,indemnify and keep hmmlaa the City of Cupertino against
liabiliticajudgmenu.cmuandnpanaes which may,in any wayuccrue agairea Odd City AIR HANDLING UNIT U010,0W CFM)
It consequence of the graining of this permh. - n - /
AIR HANDLING I1N1'I'(OVf:R IQOW CPM) (._]L� LC_ 7J�C G
/�zZ^- GI-�_ /-/L-5 a7
signmAre arnnpheamrcnmmelar TD., BxLinusT HooD(wfDuen PLAID
I IAZ.ARDOUS MATERIALS DISCLOSURE HEATING UNII'(TO ISJUD0 BTU) Date Receipt
Will the applicant or future building occopsnt note or handle hazardous mataiAl
asdcfinod by the Cupertmo Municipal Cade.Chapter 9.12,And Ne lleahlb and Safely 1112A UNG UNIT OVER I00.000 BTU) TOTAL: +cSS �I
Cod,station 25532(a)1 VENTILATION 17AN(SINGLE RESID) �(�
EI Yes Ci Nu
Will thea licunmrluwrebuildin tux mrdevi<awhiehemit BOILER-COMP(JHP OR IOO,OW BTU)
ISSUANCE DATE
PP g«cuPan equipmen
hmallous air con0minams As defined by the Bay Area Air Quality Management BOILER-COMP(OVER 1110,000 BTU)
TsWn'! r M
❑Yes 3'N" NEW RE,SIDENI'IAL MECH. SQ.IT.
I have salt the bamrdom materials ou.inementx trade,Chapter 6.95 of the JAN 12 1994
Califomia Health&Safety Code,Sections 25505,25573 and 25534. 1 understand that
it the building does nor currently have A tenure,that it is my responsibility to notify the
ceupant of the requirements which must he and prior to issuance of a Certificate of
occupy CI lY Ur t urttt I mU
Owner amhomcd agcm Dare TOTAL:Ty-IT ISSUED BY: V C�
OFFICE