26508 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO R IL)Ih ' .LE RI AL PERMIT NO. a
APPLICATION/PERMIT PLUMBING-MECHANICAL 2 6 5 0 8
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS ///� Cryo SANITARY NO. APPLICATION
S���UBMHTAI.DATI
/ W UJ NITM I.OTp
O SNA .�•r� {ONE: s„— Opy'{gVfe'1'O NAp7E: ^,�''C NO: NIC 1�CVONTROLp
a C—Jr`/Y.16// IGII// JL/Y Ileu' 1
•ARCHITECDENGINEER: LIC NO: A ^ F-dan LO 117a JW-A ❑
nd
CONTACT: PHONE: QTY. R/ ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELEC I' P U MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL
I hereb firm Natl am licenscdunder fC a lug commencin B
pC7 ya provisionso p ( gwiN
GOOF Dam a O 'Jiyis' J fthe Business aC Ylicense is in PANELS
[Q00U0 Licem j_ ll!(ct
- N sass PANELS0AMPS
why Dane Contractor 201-1000 AMPS
7 Orn Z_ R [in CTS D 10 OVER 1000 AMPS SQ.FT.FLOOR AREA 5/SQ.FT.
O Z—p I understand my plans shall be used as public records.
P w F W SIGNS ELECTRICAL
LicenzeJ Pndessimad
Zy.CG OWNER-BUILDER DECLARATION SPECIAL CIRCUIT'MISC.
Ko wu I hereby affirm Nm 1 am exempt from the Cm radon's License Law garde
Fw�i following lesson(Section 1031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INS
which require,a permit In consumer,alter,improve,demolish,m repair any structure
zed}7 prior to its issuance.also requires the applicant for such permit o file a signed statement POWER DEVICES
W a00 thin he is licensed pursuant 1.the provisions of the Connector's License Law(Charter
ay 9commencing with Section 0000)of Division 3 of Ne Business and Profession Cade SWIMMING LELECIRIC
Ko r b ) VALUATION
Iy_ec
orthat 7031.5 by
Nertfmmandthe basis subjetilleedl ctstheexemptt to civil kImmm
of OUTLET -SWITCHES-FIXTURESs
AZT Scullin flanal iv allyhu applicant linapernil subject the applicant to civil penalty of
G not more than five hundred dollars(S5m).
f=O NEWSIDFJJTIAI.I:LECIR .PT.
pe t: ❑ LauwnernfNepmpcny.nrmyempinyedorofemd for
rsaleinnlc c0m.Businesn.s STORIES TYPE CONSTRUCTION
6'i- will dvfic%bons and Be,structure Contractor's
Licese Law close,
not apply to
and Professions Cade:The ves thereon.License law don or apply lf an owner of
property eche buildsnrinryrovex Ncrcam,undwhodocs such work M1imulforNrough his
however,thebuildi building
Nat vehimprovld within
neye rofemroffetcd theow. r-f. OCC.GROUP RES.UNITS
however,Nc have
the
burden of poem is hat he thin of build of c prove on,Nepose of TOTAL:
builder will hove the burden of proving that he did not build or improve for purpose of
ale.).
❑ Las uwneroflhe prolxny,am exclusively contracting with licensed contractors to Ql Y. PL BING PERMIT FEE FLOOD ZONE APN
construct the projua(Sec.7314,Business and Professions Cade:)The Conracmr's
License Low does not apply loan ovorrofpfopeny who builds orimproves thereon,and PERMIT ISSUANCE
whocomacte for such projects with aconmwwgs)Iicensedpursu at write Contractor's ALTER- )
License taw. DRAIN&VG -WATER FEESUMMARY
❑ I am exempt under Sec. B&P C for This reason BACK FLOW PROTECT.DE OUTSIDE FEES
SANITARY YN
• Dae A
DRAINS-FLOOR,ROOF,AREA.GOND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
1 hereby affirm than 1 have,«nificate of con y dmm mDSCsurt,or aab C.)woe of RECF;IIT#
ars all mpape
oy«tu da cpn� rfa f py Ncrcof(Sec.JSW.fabCJwhich FIXTURES-PF,RTRAP
1�(aygyld VF/y PARK PY:E YN
Policy# s -'//nJ E(/ / GAS-EA.SYSTEM-]INC.4 OUlLEfS RECEIPTM
Company BUILDING DIVISION FEES
❑ Certified copy is here y fume he . GAS-EA.SYSTEM-OVER 4(EA) PLANCIIECK FEF.
Ccnified Bogy is filed with the city inspection division GREASBflNDUSTRL WASTE I
NTERCEPTORR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE'YRAP SOILS FEE
COMPENSATION INSURANCE
(TMssenion needmtbecomplemdifthepermil isficamehundrWdollars(SIBB) SEWER-SANITARY-STORM EA.200FT, ENERGY FEE
or less.)
I ccnify that in the performance of Ne work forwhich Nis permit is ismed,Ishil1 WATER HEATER WIVENT/ELECIR
and employ any person in any manner so as to become subject to the Workers' PAID
z Applicant Compensation Lawsof Colifomia. Date WATERSYSTEWMEATING Dam Rettiptp
z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you shouldREFFF
DENTIAL PLMB. SQ.FT. TOTAL:DO become let to Ne Worker's Comirmat ion provisions of the labor Code.you mum7forthwith comply with such provisions or this permll shal l be deemed revoked. BUILDING FEEy Q CONSTRUCTION LENDING AGENCY SEISMIC FEEDzIhmrbysffimt Wut there is a construction lending agency for Ne erformance of
V O the work for which this permit is issued(Sec.309],Civ.C.) L ELECTRIC FEEIxmle,'s Name
pULenders Address ECHANICAL PERMIT FEE PLUMBING FEEI ccnify Nal I have read Nis application and same that Ne above information is
correct. l agree no comply"id,all city and county ordinances and slam laws relating toSUANCE MECHANICAL FEEW) building conswction,and hereby amhoria«presentatives ofNiscity w erneruon the
V z above-mentioned progeny for inspection purposes. ADD TO MEC11. CONSTRUCTION TAX(We)agree wnave,indemnify and keep harmless the City of Cupertino against
Iiabilitin,judgments.cost and expenses which may in any way accore against mid CityLING UNIT(TO 10,1100 CFM)in conseyuencc of Na gmi ing ofNix permit.
ING UNIT(OVER HIL"CEM)Signaare of ApplicanaComractor Dale HOOD(WNUCp
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.00`0 BTU) Date Reccipta
Will the applicant or future building occupant awn,or final harardous material
as defined by the Cupertion Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100.000 BTU) TOTAL:
Code,Section 25532(a)Y
CI Yes �Im VENTILATION FAN(SINGLE RESID)
BOILER-COMP(JHP OR 100,000 BTU) P'LSXAJCE DATE
Will air o icadmarts s building by he ray Am.Air Cook,M.a,,mes nl rY J��
Distrdous air ummminants as defined by the Buy plea Air Quality Mmagemem BOILER-COMP(OVER 100.000 BTU)
Uisvin'!
CII
Yes olzo NEW RESIDENTIAL MECIL SQ.IT. {/AA1 Q �aa�
I have mad the Interactions maerials requimmen.under Chapter 6.95 the c kI ['
California Heath&Safety Code,Sections 25505.25533 and 25534. I udders d that V �J
fthe holding does not curreed, ntlyhavea tenant.that it is my rnponsibilityto lifYNe lI Ur Lut- l f
oc.,,mm o ayuireme he met prim nm issuance of a fcarn of
(kcapane !.�.5f!J� I 1pS
Owner or #armed agmde- Dale TOTAL: ISSUED BY:
OFFICE