26584 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY II
CITY OF CUPERTINO - .F.,NUCAL PERMIT No.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 26584
BUILDING PROJECT!'IDENTIF'ICAT'ION
BUILDING ADDRE
S�S:
/�'/�� �//I \ `R^ 9 ``tea SANITARY NO. A�CATIONSUBMfITALDATE
2� U,IITla \D LOT is ��✓
OWNERSNAME: PHONE: ONTRAC
[CTORMP.
'SNA : /�, l LIC NO: NP] CONTROLq
�ARCHITECTANGINEF.R: LIC NO: ADD ESS4wN
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1'1 1 CJ
p x+>� 1 AL b 4ttU
rONT :::: PH �. BUILDING PERMIT INFO
�,�� �� �� .QTY. ELECTRIC PERMIT FEEPERMIT ISSUANCELICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTI JOBBDESCRIPTION
Matz offirmthat l am licensed underprovisionsofaapoer9(commencing withFDOO )dfDiviskm 3of the Business end Prnfessieas Code,and my license is in PANE S
< effect.U UP T0200AMP5Q Lic.Mco Contractor 1, 10 201-HIW AMPS
z OtO1it'� RCHITECPS DECLARATION OVER 1000 AMP SQ.FT.FLOOR AREA $SQ.FT.
O z-❑ I understaad my,lnns shall he used as Public records.
Fat rat SIGNS ME [CAL
a Licensed Professional lJ 7-�
�yata OWNER-BUILDER DECLARATION SPECIAL CI UIT/MIS l9
WW gi. 1 hereby affirm that 1 am exempt from the Cosim,C.a:A,,Law for the
m3ay following reasma(Section]OJ L3,Business and ltofneiona Cody.Any cirymcounty TEMP.METER OR El `1 (gyp u ,D
C<rt
which rquires a permit to coman
nstm 1.cher,improve,demolish,or impair y structurre
>.-` poor to its issuance,also requires the applicant for such Permit file a signed statement POWER DEVICES
<0 that he is licensed prommtuo the provisions ofthe Contmcmes License Low(Chupter
Mya4a 1 9(cmmiteram,with SectionT000)of Division 3 of he Basinexprod Professions Code) SWIMMWG POOL ELECTRIC VALUATION
Www or Nm he is exempt therefrom real basis for Ne alleged exemption.Any violation of OUTLETS-SWITCHES-FI%TURFS
tza Section 9031.5 by any applicant for a permit subjects the mpl icantto a civil Penalty of 111...
�'O root mom then five hundred dollars(55(10). NEW R55[DIiM'IAL.ELECIR SQ.FT.
� ❑ I,asownerof Neproperiy,ormyemployeeswithwugesusthei raolecuntpensotion, STORIES TYMCONSTRUCI'ION
y,3_ will do she work,undthe suuc..m isnot inendedamffertd foreale(Sm.]Oa4,Business
and Professions Code:The Convector's License Law does not apply to an owner of
property who buildsorimproves thereon,and whmdoes such workhimselforthrough his OCC.GROUP RFS.UNITS
wnemple,res,provided that suchimprovementsum not intendedorofl'ered formic.IL
however the building Or improvement is sold within one yearnfrnmpletion,theowner. TOTAL: (y1 .1
builder will have the harden of proving that he did not build or improve for purpose of
wiled, QTY. PLUMBING PERMIT FEE
❑ Las ownerofthe property,amexdusivelyconwcting with licensed conuecmrsto FLOOD ZONE APN
Lmstruct the project(Sec.7044,Business and Professions Code:)The Com actors
icense Law does not apply..anownerofpropedy whmbmidamimproves Hereon,and PERMIT ISSUANCE itYD
whocontmcte mrsucb projects with a contractors)licensed pursuant to the Contracmrs
License Low. ALTER-GRAIN&VENT-WATER FF O FEE SUMMARY
❑ 1 am exempt under Sec. .B&P C for this mason OUTS1D. FS
BACK FLOW PROTECT.DEVICE SANITARY Y_N
Owner Date DRAINS-MOOR,ROOF,AREA,COND. RECEIPT,
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ I herebyaffiam that l have armificmeofcomsem to self-insure,ora cenificatenf FIXTURES-PER TRAP RECEIPT,
Wmrkere'Compcnsatinnlnsurance orncenified copy thcrcof(Sa.3800,Lab CJwhi<h PARK FEE YN
coven all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT g
Poliey p BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4 BAU PLANCHECK PEE
❑ Cenificdcopyiehemb,ohnished. I�
❑ Certified copy is Bled with the city inspection division. GREASFJINDUSTRI.WASTE INTERCEPTOR GRADING FEE L �•V V
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS PER
COMPENSATION INSURANCE
('(hie section need not becumpleted ifthe Permit is forma,hundreddollma($11(ft SEWER-SANITARY-STORM EA.200FU ENERGY FEE Z.Q.vV
orless.)
I codify that in the performance ofthe weak for which this Permit is issued.I shall WATER HEATER W/VFIJT/ELECTR
not employ any person in any manner so as to become subject to the Workers' PAID
Compenvtion Lawsof C.1dimnia. Data WATER SYSTEMOREATING Dote Receipt is
0 Z Applicant '` —
z Q NOTICE TO APPLICAM':If,after making this Certificate of Exemption,you should NEWRESIDENTIALPLMIL SQ.F`U IJ aT TOTAL:
Pto became subject to the Workers Compereaetion provisions of the Labor Code,you must
ai 7 forthwith comply with such provisions or this permit shall he deemed revoked. BUILDING FTE ` AM
a Q
CONSTRUCTION LENDING AGENCY . SEISMIC EEELl
. z I hereby affirm that is a construction lending agency for the pormmence of TOTAL: YI x`18 ELRCfItIC FEE
L) O the work for which NPermit is Peit is issued(Sec.3097,Civ.C.)
Lender's Name D-t PLUMBING EEE F Lood,rs Address QTY. MECHANICAL PERMIT FEE 1
L) I certify that 1 have mad this application and state that be above information is MECHANICAL FEE
>"t 4 cored.l ugme m comply with oil city and county ordinances and some laws totaling.. PERMIT ISSUANCE 2--W
�-' building construction,and hereby authonm representatives ofthis city to,nterupmnthe CONSTRUCTION TAX
L) Z above-memmeed property for inspection purposes. ALTER OR ADD TO MECH.
t--t (We)agree mama,indemnify and keep hornless the City of Cmediam against
liabilities.je eau,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,M)CEM)
in con set pfthe gran it ng of P ix pen il.
6 AIR HANDLING UNIT(OVER 111,000 CFM)
Signature of ApplicandisCodIfictor Date EXHAUST HOOD(WNUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO FIRM BTU) Use Receipt,
Will the applicant or future building caeopmt store or handle hurallous material HEATING UNIT(OVER I W.000 BTU) TOTAL:
cue defined by the Cupertino Municipal Code,Chapter 9.12,and Ne Health and Safety
Code,Section 25532(a)? VENTILATION PAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
BOIf.E0.-COMP(JHP OR IfO,glO BTU)
Will the uconta manta rcrefineg by the Bay Arm Aenmuality Management
•
hazardous air contaminants m defined by the Buy Ara Air Quality Management BOILER-COW(OVER 100,1100 BTU)
District?
❑Yes ❑No NEW RESIDENTIAL MECILZTESQ,FT. LOCI lg
1 have mad Nusan
e hlmus materials requirements under Chapter 6.95 of the OCT 12 1994
California Health&Safny Code,Sections 25505.25533 and 25534.I understand that y,
if the building does not currently have a tenant.that it is my responsibility to notify the CII I ur uuc-,:-,quij
occupant of the requirements which most be met prior to outcome of a Cor ificme of
Occupancy.
Dwnenrr auflumrd agent Dom TOTAL: 41 .7 ISSUED BYE-'✓� a
OFFICE