26588 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY V
CITY OF CUPERTINOPLUMBIN11 ILUI .-ELh.CTRICAL PERMIT NO.
BUII,EING DIVISION APPLICATION/PERMIT G-MECHANICAL. 26588
BUILDING1•ROJECT IDENTIFICATION
BUILDING ADDRESS! Tig (6` D L_+ SANITARY NO. APPUCATIONSUBMITTALDATE
2.l :io UN`IITTM �JOLOTg
OWN12RS NAME: PHONE: CONTRACTOR'S NAME: f `S LIC NO: N/C 'ROLM
III •�ARCIIITHCI'/ENGINHF.R: LIC NO: LISS: CA-LW—&"
A-L I & IL7 D ONOT `IMW 'AL COM
CONIACI': ^ PHON. t BUILDING PERMIT INFO
y/ QTY. ELECTRIC PERMIT PEP.
PERMIT ISSUANCE B G ELECT PLUMB MF:CJi
!/ "'t Uti'Cy11'
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL. JOB DESCRIPTION
ozz I hereby affirm thttl amlianxd underpmvisionofaapmr9(commencingwith ��•X
N00 Sectors 7")of DlVnl 3uf Ne Business and Professions Code,and my license is in PANELS I YW�
Fa�F full force andeffen. 52�8'Z.'7'� UPT02MAMPS S
Z p`j License
y Q a Dam s Comrxtor b o a 201-1000 AMPS
FD ARCIII'TECI'S DECLARATION SQ.FT.FLOOR AREA S/SQ.FT.
Oz_Q OVER IOW AMPS
I understand my plans shall be Deed DECLAR TIO
cr'4thJ SIGNS ELECTRICAL ( n
�a <
Licensed RofcssionelOWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC. 15 ,g 100 (o 7—
�aOaU I hereby affirm m that I nexempt from the Conwemrs License Law for the V
[v13ay following rearm.(Section]031.5,Business and Professions Cale:Any city or county TEMP.METER O0.PoLE INST.
L" which requires a permit to construct,alter•improve,demolish,or repair any sanctum x
poinrtoit,issuance,aBorequirestheapplicantforsuchPermittofileasignedstatement FEWER DEVICES
L'Q 0 that he is licensed pursuant to the provisions of the Convector's License Law(Chapter
y�6�y SWIMMING POOL ELECTRIC
xeLL. 9(commencingwith Section and tof Division Sof the Business Professions VALUATION
W_rut Smithat 7031.5 by any applicant
the Perbasmit subjects be exemption. Civiny l raft,of OUTLETS-SWITCHES-FIXTURES t �/l �( (, ea
��< Section than by hundred
dollars(SSW).
subjects be applicant tovcivil penalty of T{,/ `-f/
E�Gof more then five hundred Donors(yemp.
NF.W RISIDIiNT1AL ELCCTR SQ.FT. •1 STORIES TYPE CONSTRUCTION
W n❑ I,usowncmftheproperty.ormyemployeeswithwagee nthetree.704.Bminon,
a3� will donhewons ander she Contrsoatinvnense Lawdr draw
apply to ano owner
property
Profession Cafe:The Convxmrs License Lew such
or apply m an owner of
pntpemwyces,pmvidedpruvesthimp vndcntsamssuchworkoroffe dfrmle.ough his
employees,proviJedthm suchimprovememavmnotimm�dedoroffend forsale.If, ^ OCC UP RIiS.UNITS
however,the Inildingorimprosloolm is sold within oneyearof completion,the owner- TOTAL: . 1
builder will have the burden of proving then he did not build or improve for purpose of
le')' QTY. PLUMBING PERMIT FE FLOODZONF. C APN
❑ I,el ownpr project
(S opcny .Business
uaivelad Profession,h liee)'Me C dowlato
onnmct the project(Sec.?046.Business end Professions GodeJ..e Comrarer's
contracts
pplytoanownaofpropenywhnsedI Innocent
to the Contractor
PERMIT ISSUANCE
who seLmvsIorsuch projects with aennvucmr(s)licensed punuannothe Commmor's
License Ww. - ALTER-DRAIN&VENT-WATER(EA) •ES ARY
❑ 1 nm exempt under Sa. .B&P C for this reason BACK PLOW PRO"1'ECI'.DEVICE ID
SANITAR N
Owner Date 'DRAINg-PLOORROOK ARI?A,COND. RECM
,
WORKMAN COMPENSATION DECLARATION SC L X 4p Y N
ElThereby ufOtm On lM1aveucenifcne of consentm selGinsum,nracenificvm of FIXTURESPER TRAP CEIPI'g
Workers Compensation Insurance en a certified copy dtereof(Sm.38W.UhCJ -
which Y N
rs ul I employee's under this permitGAS-F.A.SYSTEM-1 INC.4 OUTLETS RECEIPT M
Policy at U .DING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK rusli
❑ Cenilmdcopyisherebyfamished. .4f�
❑ CenifieJ copy is filed with the city impation Division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING H Z, •V
CERTIFLCATEOFEXEMPTION FROM WORKERS' GREASETRAP SOIL 'E
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one hundred dollars($1000 SEWER-SANITARY-STORM EA.2WFT. ENERGY FEE
V less.)
I certify that in the performance of rhe work for which this permit is issued,l shall WATER HEATER WVE1s T/ELECIR
on employ any Person in any manner so as to become subject to the Workers' PAID
Compensatio Lavot.f California. Date WATER SYSTEMIMEA, NG /� Date Receipt
O z Applicant �OCl' 1
NOTICETO APPLICANT:If.after making this Certificam of Exemption,you should NEW RESIDENTIAL PI.MB. SQ.PT. TOTAL:
pJ become subject to the Worker's Compensation provisions ofthe Labor Code,you must BUILDING FEEf1 ? forthwith comply withsuch provisions or this Permit shall has clamed revoked.
CONSTRUCTION LENDING AGENCY SLISMIC LLE tu 01
1 hereby offvm thanhert is a conswnion Imding agency for the perfommnce of
L) O the work for which this permit is issued(Sec.3097,Civ.CJ TO'T'AL: r ELECTRIC FEE
lenders Name PLUMBING FEE y
0 lenders Address Q'rY. MECHANICAL PERMIT FEE •7g
LUT1 I certify that 1 have read this application and state that the above information is MECHANICAL.FEE 4
>" Correct. l agra w Comply with all city and county ordinances and state lows reining n PERMIT ISSUANCE 'L .
P• building construction.and hereby authorize represcnta0ves of this city to enter upon the CONSTRUCTION TAX
V Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Iiuhilities,judgmems,costs and expenses which may in any way acme against said City AIR HANDLING UNIT(TO 10,000 CFM)
n.nx ueme.fa6raini nRhisa it.
AIR HANDLING UNIT(OVER 10,000 CPM)
h14-
Signanrt of APPlicant/Contrscten Data EXHAUST HOOD(WIDUC9) PAID
FiAZARDOU TERIALS DISCLOSURE HEATING UNIT LTO TOE"BTU) Dam Receipt
Will the applicant or future building moment snore or handle hazardous mammal TREATING UNIT(OVER IIXt,gKI BTU) TOTAL:
us defined by the Cupertino Municipal Cade.Chapter 9.12,and the Health and Safety
Code,Section 25532(x)1 VENTILA9'ION FAN(SNGLE RFSID)
❑Y. ❑No
ISSUANCE DATE
Will Nee licamorfutumbuildin tuu uimentnfdeviceswhichemit BOILER-COMP(3HPOR 10D.OIXI BTU)
PP S by the W P
• District? air comuminnn as defined by the Bey Area Air Quality Management BOILER-COMP(OVIiR 100,000 BT11) L J
District?
❑Yen ❑No NEW RESIDENTIAL MECH.
6O`ur-SQ.FT. CT 12
I have read the hazardous materials 5505.2ments under 34.1 un 6.95 of the 19g�
ifthe uil Ing lth&dues
Safety Code,ave Sections itis and25534.1undemmnd that
ifthebulldingdasnmcunts currently must ant etprirmysmanceiofa responsibility the C,fIYOF ��rtN�
occupant ollhe requirements which must he men prions issuance of a Certificate of t
Occupancy.
Owner m iota odzed agent Data TOTAL: ISSUED BY:
OFFICE