26574 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BIL 1 .-L.E.TRI AL _ PERMI'TNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL, n C A
BUILDINGPROJEC.'1'IDRNTIFICATIf1N G J L�
BUILDING ADDRESS: �� lit
-4965-+ � SANITARYNO. APPLICVDONSUBMMITTIALDATE
/V_+`il7wt U`NIIT0 `6 J ' LOT« G� l
OWNERS NAME: PHONE: CONTRACTOR'S NAME: I.ICNO: NIC CONTROL«
SLC 94 K( H bT • 2
ARCHITEC tENGINEER:ACTieLLIICNO: ADDRESS O
CONT /Yl ( y Pio r. 1'1 CN t (F 1 A (lvCP!J LD A
03
LY ( MY. ELECTRIC PERMIT FEE BU ILDING PERMIT INFO
UIpG ELECT PLUMB MECH
U ZPERMIT ISSUA ,rp Fl[�l lnYx�
LICENSED CONTRACTOR'S DECLARATION APPLIANC -RESIDENTIA JOB DESCRIPTION
❑KZ Iherebyafri.that lam licensed under provNionsof Chapmrq(commencing with
(000 Section]000)af Division 3 of the Business and Professimcs Cade,and my frouseis is pA
W65 ;;°e�x�m3effern Lic.«SGf3Z7S SYDwL
TO200AMPs
vFi�ot Date q( eantracmr Lf n 01-I"AMPS
Fpm CIIITECrrwtc,DECLARATION SQ.Ief.FLOOR AREA $ISQ.PT.
0p=❑ OVER 1000 AMPS
I undersand my plana shall he used te public rttoNs. rX�.r,
Sty SIGNS ELEkj' tl
0 V-a w
6 ya LLooniestLooniestfes148
Pro
sional YC V-�
OWNER-BUILDER DECLARATION SPECIAL CI /
XOaU I hereby off that 1 e(n exempt from the Contractor's License Law for e /l71's��
�LLOafollowing reason.(Section]031.5.Business and Professions Code:Any city or unty TE P.MR P6 1
which requires u permit to construct.alter,improve,demolish,or repair any show
useu Y prior to its issuance,also requires the applicant for such permit m file a sign eA steamers PO VIC
<p that he is licemed pursuant to the provisions of the Contractors License Law(Chapter
d ❑o� 9(commencing with Section 7")of Division 3 of the Business and Professions Code) SWIM POOL EL VALUATION
y,_y or that he is exempt therefrom and the buts for the alleged exemption.Any violationaf ��� _
ZQ Section 7031.5 by any applicam for.perrnitsubjects theapplicart to a civil pe unity of OUTLETS-SWITCHES- XTURFS -'I �J
Fp- not more than five hundred dollars(SSW).
L ❑ NF. F.SIDfiMI'IALE Cflt SQ.FT. 1515'.
e� ��}} STORIES TYPE CONSTRUCTION
� � ❑ hasowrk,andsproperty.ormyemployeftorafferederegeaasalei(sole compHmonen, dJ .9
LL3-- will dnthewons andthe he Contructure tractors
is License
for ot apply
and erofessiona Code:The Cummnon,License Lew does not apply lf rt owner of
property whohuilAs or improves thereon,andwbndmssuch workhimmlfonlwugM1 his OCC GROUT' RES.UNI'T'S
w ever,tyebuiprovidedmprovehimprovem%ithim one earcdedmoffereddocow.o- ^
haweer ,will avec a ndooro proving
issoldhe did
nt buildo improve for purpose of TOTAL: - 9
builder will have the burden a(proving that he Aid not build m improve for purpose of
le.). OOD ZONE APN
.
❑ [,as ownerof the property,an exdusivelycono-acting with licensed contractors to QTYPLUMBING PERMIT FEE Fl
cum uct the pmject(See.]Ono,Business and Professions Cede:)no Contractor's
License Law does not applym an ownero(propenywhobuildam improves there .and PERMIT ISSUANCE. 2-UP
whocontrncts frnsuch projects with acontramar(s)licensed pursuant to the Convector's
LicempLT'ER-pRAIN&VONT-WATLR(1?A) FEE SUMMARY
❑al Low.em exempt under Sec. ,B&P C for this reason BACK ROW PROTECT.DEVICE 1 .
SANITARY Y N
Owner Date pRAINS-BOOR,ROOF,AREA,COND. RECEIPT«
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Iherebyaffirm that l have acmificaicefconscoto self-insure,ora co iftcueaf FIXTURES-PER TRAPRECEIPT«
WorkersCompensation humanceara cenlfied copy thereof(See.3800,I.ab C.)which PARK FEE Y N
covers all employee's under this Permit. GAS-FA.SYSTEM- INC.n OUTLETS RECEIPT p
Policy« rmBUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4ESA) PLAIJCHECKFEE 20-00
❑ Cenifiedcopyixherebyfumishcd.
❑ Certified copy is file)with the city lnspenion division. ORGSEANDUSTRL WASTE INTERCEPTOR GRADING FEE Z-Tv
CERTIFICATE OF EXEMPTION FROM WORKERS" GRGSI?TRAP SOILS FEE
COMPENSATION INSURANCE
(This sectiannsednat be completed ifthe permit is future hundred dollars(SHIP SEWER-SANITARY-STORM EA.201 ENERGY FEE D w
or Ins.)
I certify that in the performance of the work for which this permit is issued,I shall WATER HEATER W/VEM'/ELF.CTR
of employ any person in any manner so as to become subject to the Workers' PAID
z Compencationlawsof California. Date WATER SYSTEMIMIi, TING Dam Receipt«
Applicant
ta NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RMI DENTIAL PTOTAL:
become subject to the Workers Compensation provisions of the Labor Code,you must
�. � forthwith comply with such pmvisimsorchis permit shall be demand invoked. BUILDING IEE
❑r �] CONSTRUCTION LENDING AGENCY SEISMIC FEEIs
1 hereby off tom there is a construction lending agency for the performance of
U O
the work for which this Permit is issued(Sec.3097,Co.CJ TOTAL: ELECTRIC FEE
3
L<ndor's Name PLUMBING FEE
0 F Lender's Address QTY. MECIIANICALPERMIT FEE -�
O IUI certify that I have read this application and state that the above infmmadon is oq MECHANICAL.FEE6.
correct.I agree m comply withdl ciryand orrm itrdinarces and state laws relating in PERMITISSUANCE D(i-
buildingconstruction,and hereby authorial represenativesof thisciry m C
outermost the CONSTRUHON TA
U Z above-mentioned pmpeny for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liahilities.judgmems,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
quencc of the gran ing of th' permit. AIR HANDLING UNIT(OVER 10,0M)
00 CF
Signature of Applic Cum Dat EXHAUST HOOD(W/DUC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 RTU) Dam Rtteipp
Will theapplicum or future building mocupantstoreor handle haamdom material
as dHEATING UNIT(OVER 100,000 BBTU))
defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and safety TOTAL:
Code.Section 25532(a)'! VENTILATION PAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
WilitheapPlicantorfutumbuildingwcupantumequipmentordeviceswhiehemit BOILER-COMP(31JP OR I0Lf100 BTU) \
`1 1
Jmaudous air contaminants as defined by the Buy Arca Air Quality Management BOILER-COMP(OVER 100,000 BTU) ;
tsWcREDf
Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. 'OS-� OCT1 2
1 have read the haurrdous materials requirements under Chapter 6.95 of the 1 1 1994
California Health&Safety Code,Sectiare 25505,25533 end 25530.1 understand that (jl I
if the building does not currently have a tenant that it is my responsibility to notify the + Vr LurC'}{f f
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
Ownenu authoriced agent Date TOTAL: Iqj1 -S$ ISSUEDBY:
OFFICE