26000 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOau'r I, .- E., Rf7AI. PERMITNO,
APPLICATION/PERMIT PLUMBING-MECHANICAL r�C n
BUILDING DIVISION BUILDING PROJECT IDF,NI'Ik7CATION LOIO OC
BUILDING ADDRESS: /1�/ SANITARY NO. APPLICATION SUBMITALDAT
21d Z� /-.f) o—nn S OL� ✓Y UNIT# LOT# I O
OVILIal NAME:• PHONE: CO RALTOR'S AM}i: ,IC NO/ `
• IO t.J.0-P14 iVL 72.S—O Z e fL`n'- / (Ch^ NIC COM'ROL
RCHITEC"GINEER: LIC NO: ADDRESS:
-J �Cl62E- Kaf. ❑
coNrnn': PHONE' BUILDING PERMIT INFO
�]
QTY. ELECTRIC PERMIT FEE
GI L�7 2700 PERMIT ISSUANCE B ELE T PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
Ihemb ffinnthail am licensed under p ( gwith JOB DESCRIPTION
pmt y a and Poians ions C tag commcncin
--100I-. Sealor]BOd)nfect. nJuf the Businessland Professions Code,and my license is in ppNpyS
yUF fullfimceand effect. UPT0200AMlS
'i I.icens'c Cl ass Co. /
w,Q]z Dam COOTS DECLARATION 201-1000 AMPS
Z C ce,— I understand my planaRSM1olllhc u cd asps l c rcOVER I"AMPS � d � �FL $/S0.ET.
O-z—D
1=.r_s FID SIGNS ELECTRICALr`x n , e 1
2yLicensed ro
�j se]Pfessional II`V/f VT E-
Acle OWNER-BUILDER DECLARATION SPECIAL CIRCUUFMISC.
XC wu 1 hereby affirm that 1 am exempt from the Contractors License Law for the O 'I
aLLpa folluwingismoa(Section)031.5,Business and Professions Code:Any city or county TEMP.MLTERORPOLEINST. WE
�..C.' which requires a permit to consumer,alter,improve,demolish,or repair any strvcture 1 E J'
,WY7. priorm its Issuance.also reclaims me applicant for such Permit o file a signed statement POWER DEVICES
C that be la licen ed uo the f the Contractors License Law(Chapter
_ O pl Seco provisions o ( p cr
dkm 'I(commencing with Section]000)of Division3nf the Business and Professions Codd SWIMMING POOL ELECTRIC VAI
ta_nn or Nat he is exempt therefrom and the hasis for the alleged exemption.Any violation of
hZQ Section 7031.5 by any applicant for apennit.subjects the applicannoacivil pemlty of OUTLETS-SWITCHES-FIXTURES
not more than rise handled dollars($500).
oco
W 0 [11.asuwneroftheproperty,ormyempluyeeswithwagesvt eirulecompemation, NEW RESIDENTIAL ELECTR _SQ.FT. STORIES ]'YPECONSTRUCHOf
a will Jo the work.and the structure is not mmadedoroffered foraale(Sec.7(4n,Business
and Professions Code:The Commences License Use does not apply to an owner of
c)wnenywyces.provii true thimpmvemenod nwihwdeduroffemd hrough his
cve,me bulding.,itprovehimpissold sale notimended oroffemd forsale.If. OCC.GROUP RES.UNITS
buwevcw the have
the
bur improvement is sold within of build ofcomove for purpose of TO]'AL:
hander will have the burden of proving that he did not build or improve for purpose of
alt.).
❑ Las the Project(Sol.
04,amesiness tyromraevdgs Comemede Comemetvo QTY. PLUMBING PERMIT FEE n.00D LONE qPN
construct the project(Sec.to air
insimees and Professions or Improves
The Cemon,and
License Law dmsnm apply men Oh a commrrrpcny wM1nsebuilds ouant todre Coean,and PERMIT ISSUANCE
whence Lose for..wchprnjemswilhucunmucmr(s)licensed pursuanuothe Commnors ALTER-DRAIN&VENT-
LfaenaeLaw. WATER(EA) FEE SUMMARY
❑ I am exempt under See. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
Owner Date SANITARY YNI
• DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMRIiCEIPf#
COMPENSATION DECLARATION SCHOOLTAX Y N '
❑ Humbyaffirmthalhaveazerificamofconaem to self-insure,orecenifcae of FIXTURES-PERTRAP RECF.IIT#
Workers'Compensation Insurance or a mmiled copy thereof(Sec.3800,Lab CJ which PARK FEE Y N
covars a ll employcesyn r3Biaygmi� GAS-EA.SYSTEM-1 INC.4 OUTLETS RF.CEHT#
PolConeeyan AAl I--1144 BUILDING DIVISION FEES
p y GAS-EA.SYSTEM- (EA)
OVER4
0 Certified copy is hereby famished. ( PLANCHECK FEE
❑ CenifieJ copy is flet with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING ME
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP SOILS TEF.
COMPENSATION INSURANCE
(rossedion need not becompleted ifthe Permit is for ane hundred dollars($100) SEWER-SANITARY-STORM EA.
lass.) 2WF4. ENERGY FEB
or
I certify that in performance ofthe work for which this permit is issued,I shall WATER HEATER WNEM'43LECTR
not employ any person in any manner so as in become subject to the Workers PAID
z Compensation Wwsof Califomm. Data WATER SYSTEM/TWITING Date Recciptp I
Q O Applicant
z NOTICE TO APPLICANT:If.after raking this Ccrufcate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.ET. TOTAL:
f^' ` heccom.suhject to the Worker's Compensation provisions ofthe Labra Cod,you must
� , fonhwlth comply with such provisions or this p[mul shall b,deemed revoked. BUILDING FEE 2 ��
y O CONSTRUCTION LENDING AGENCY SEISMIC HE
Z) z 1 hereby affirm that them is a con.lMellon lending agency for the pafformamea of
U C) the work fur which this pc.it is issued(Sec.309],Civ.C.) TOTAL: ELECTRIC HE
Lender's Name
OU Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I certify that I have lead this application add state that the above informamon is
E4 comet I agree tocomply with all city and county ordinances andrmm laws relatingto PERMIT'ISSUANCE MECHANICAL FEE
� building construction,and hereby amborice repreara advuafthls city to enter upon the
U ,z alloe-mnaimurl prepeny for inspection Fannie,. ALTER OR ADD TO MECIL CONSTRUCTION TAX
(We)agree to save,Indemnify wd keep hamless the City of Cupertino against
liabilities,judgments,costs laid expenses which may in any way accrue against said City AIR HANDLING UNIT I Q(IW CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER I0.D00 CFM)
Signawrt of Applic:mUCnmmcmr pam EXHAUST HOOD(W/DUCI)
PAID
IIAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,000 BTU) Dae Reecipt#
Will the upplierm m!mare building Occupant store or handle le.ardoas material
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Salary HFATING UNIT(OVER 100,0(0 BTU) TOT L:
Cade SeetlOn 25532(a)^ -
❑Yea 0N =RF�IDEZLMECH,
SINGLE RESID)
will rhe applicamorfulum building occupant use equipmentordeviceawhichemitOR 100,000BTU) IS A D�'E
Distrihoomencts air comnminans u defined by the Bey Area Air Quality ManagementR I00,gl0 BTU) A'p1'
11 Yea 0N ECH. SQ.IT. J-'•• IO1 have read the l oeduusmaterials uquimments under Chapter 6.95 of theCII I UfCalilrmiu Health&Safety Code.Sections 25505,25533 and 25534. 1 understand NatV f I Wr;ERTINO
lithe build' gdocs nm currently hvvcamnant,that it is my respnnsibility to notify Ne
aP t the rryulmments w ' mo be met r m issuance of a C ifieat of
Oven 1
/d
O ramh 'uJa DYE TOTAL: ISSUED BY
OFFICE