26586 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY ✓
CITY OF CUPERTINOB ILDIts.- E FRICAL PERMIT NO.
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING-MRCHANICAL 26586
BUILDING PR016C1'IDP.M'IPICAI'IOM1'
BUILDING ADDRESS: .(J r bSANITARY NO. APPLICA'T'ION SUBMfITAL DATE
2 I UNIT#IF D LOTp -
OWNERS NAME: PHONE: CONTRAC O 'S NAME: 'L�lye c N/C VV CONTROL It
(�ARCHITECI'/ENGINEER: LIC NO: ADDRESS: J
77-7 u kipuA -AvL • VA o.A-gb ❑
CONTACT: PHOP1 51 PERMIT INFO
( QTY. ELECTRIC PERMIT FEE
/V V y BLDG E ECT PLUMB ME
PERMIT ISSUANCE /4 �I
LICENSED CONTRACTOR'S DECLARA'T'ION APPLIANCES-RESIDENTIAL
TOB DESCRIPTION
OWz I hereby affirm that l an licensed underprof 9 m
visions oCTapter (comencing with
ta100 Section 70l ia`Divisio ofthe Business and Professions Code.and my license is in PANELS
Fq VE full orceandeBect. —s S�W�
ff Licensc Lic.p (_� UPT0200AMPS
fin Gy Dote Contmcmr LL 201-I"AMPS
F-yZ I s ARCHI'FEC'TSDECLARATIONOVTiR BKKSAMPS SQ.FT.FLOOR AREA 8/SQ.FT.
z0 —fin
OZ—❑ 1 mademmrd ery plans shell he used m public records.
�yJ SIGNS ELECTRICAL
6 Licensed Professional
Exc,&'< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
xaxOyU I hereby affirm Nat I con exempt from the Commcmr's Licrnse Law Fannie ( l
v131+.y fallowing remain 7031.5,Business and Professions Code:Any thym comedy TEMP.METER OR POLE INST. �I1
F 0 Q which requires a Permit to construct,alter,improve,demolish,or repair any shormae
CW}� r ro its issuance,lo, thea licaut for such uo flea si dmeement POWER DEVICES
trio regmrex pp tract gLaw
a
W LY�p thatheis licensedpursuant th Section the)of isimtsn 3 of Contractor and Pro Lvwn,Coder
Lgo6' 9(commencing with Senion]11001 of Division Sof the Business and Professiom Code) SWIMMING POOL CLECIRIC VALUATION
y(^y
.,hot he is exempnherefrom and the basisforthealleged exemption.Any violation of OUTLETS-SWITCHES-FIXTUREg �� l
�ZQSection 7031.5 by any applicant fare Permit subjects the applicant toacivil penalty of q
not motethan five hundred dollars($500).ce NEW RESIDGYIIALELECIR SQ.FT. �Oq n.�
❑ I,asownerofNepropeny,ormyemployeeswithwegesustheirsolecampensation. >rt STORIES TYPE CONSTRUCTION
y3. will do the work,and Ne structure isnot intended oroffemd for sale(See.9M4.Bminas
and Professions Code:The Cimmiscuri License Law does not apply to an owner of
propertywhobuildsorimproves thereon,add whadoesxuch work himxelforthrough his OCC.GROUP RES.0 ITS
ownemployees,powidedthat such improvementsumnot iedeadedoro(find forsale.IL
howeverthe building crimprovement is mid withinoneyearofcompletionJheowner. L.l_t /1V
TOTAL:
builder will have the burden of proving thin he did not build or improve for purpose of
sale.).
[:] I,mowner of the properry,amexdusively convecting with licensed conva<ton to QTY. PLUMBINGPERMIT FEE FLOOD ZONE APN
construct the project(Sec.]DW,Business and Professions Code:)The Contractors
License Lnwdsxsnot appfit.an.wnerof,.Ncy who builds or
improve:
w❑ mcv
forauch Projeda wiNaconvxemr(s)licenced pimprove:1,1.0 and PERMIT ISSUANCE
LicenseLow. ursuantotho ALTER-DRAIN&V
ENT-WATER(EA) FEE SUMMARY
1mexemptundeSc. ,B&PCforNismn
BACK FLOW PROTECT.DEVICE O D, ..
SANITARY Y—N
—
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RF,CEI
TIPI'p
WORKMAN COMPENSATION DECLARAON SCHOOL YN
❑ I hereby difum that l have a certificate of contain to self-insum.or a cerci route of FIXTURES-PER TRAP RECEIPT#
Worken'Coun,mattion Insurance or a certified copy thereof(Sec.3800,Lab C.)which PARKFEE Y N
covers all employee's undo Nis .it. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT M
Policy q BUILDING DIVISION PEES
Company GAS-G.SYSTEM-OVER4 MA) PLANCIIECK FEE a V V
❑ Cenified copy is hereby famished.
❑ Candied copy is filed with the city inspection division, GREASH(INDUSTRL WASTE INTERCEPTOR GRADING FEE ( rl
CERTIFICATE OF EXEMPTION MOM WORKERS' GREASETRAP SOILS FEE Y
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one hundred dollars(5100) SEWER-SANITARY-STORM EA,201FT. ENERGY PEE
or less.)
I certify that in the performance ofthe work for which this Permit is issued,l shall WATER HEATER W/VENT/ELCC'M
not e.,toy any pc.a in any manner m res to become subject or the Workers' PAID
Compensammi-owsof Califomia. Dote WATER SYSTEMfMFATING Date Receipt#
Zz Applicant
O NOTICE.TO APPLICANT:If.after real'his Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.Ff. TOTAL:
(/) become subject no the Worker's Compensation provisions of the Labor Code,you must BUILDING FEF.
gx fes" forthwith comply with such provisions or this permit shall be deemed revoked. �6( -TD
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE �(„f •�
1 hcrehy aff on that is a construction lending agency for the Performance of �f
U Z TOTAL: ��,�{{ ` ELECTRIC FEE �1
O the work for which this pcnrdt is issued(Su.309].Civ.C.) R 1
Lenders Name PLUMBING FEE
D" F Lenders Address QTY. MECHANICALPERMIT FEE
(..) I sonify that I have read this application and slate that the above infomtmion is
Rcorrect. l agree m comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FTE
Cnbuilding construction,and hcrehy auNorize toprcsentmivesofthiscity to emerupon the CONSTRUCTION TA%
U z above-mentioned property for inspection purpoms. ALTER OR ADD TO MECII.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Iiabilities,judgmenta,costa and expenses which may in any way acerae against said City AIR HANDLING UNIT(TO I O,WO CPM)
in coegrenf tg of this cmtit.
Ly
L AIR HANDLING fINIT(OVER 10,000 CPM)
Signaof ApplicunVConter v t0 Dole
EXHAUST HOOD(W/SignorinaPAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,00(1 BTU) Dete Receiptg
Will the applicant or fucose building occupant store or handle hazardous material HEATING UNIT(OVER 100,1100 BTU) TOTAL:
as deEned by tha Cupertino Municipal Cale,Corpora 12,and the Harlot and Safety
Code,Section 25532(a)? VENTILATION PAN(SINGLE RISID)
❑Yes ❑No
ISSUANCE DATE
Will theapplicant or futumbuildingoccuprt meaquiparent ordeviceswhichemit BOILER-COMP CHIP OR 100,000 BTU)
• haurdous air conmminadts as dations]by the Bay Arca Air Quality Management BOILER-COMP(OVER 100,000 BTU)
Bimini? q
❑Yes ❑No NEW RESIDENTIALMCCH. SQ.PT. (01 s
I have mud the Immolous materials regviremetns uWer Chapter 6.95 of the OCT 12 1994
Califomia Hwlth&Safety Code.Smtions 25505.25533 and 25534. I understand that
if ma building dess not cmramly have a tioum,Net it is my responsibility to antify Ne `'�x,
occupant of Nem,e requirememx which moa,be mer prto issuance of a Certificate of V(- U(ef•L-(,
Occupancy. `�I s�//��
Oil
Owned or emhorized agent Dam TOTAL: Lt �. ISSUED BY: �--a✓`
OFFICE