26085 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALLPOINT PEN ONLY '
CITY OF CUPER'PINOPLUMBINGR'IHNli-Ll,RCTRIC FERMI r NO.
BUILDING DIVISION APPLICATION/PERMIT ROJECTFIDENTIFIC 26085
BUILDING PROAE(TI'IIIN:NTR+ICA9'IpN
BUILDING ADDRESS: IDa SANITARY NO. APPLICATION SUBMITTAL DATE
l2 UNT# LOT#
OWNERS NAME. PI IONS: CONTRACT'OR'S NAME: LIC NO:
3-41J51 O&M NIC CONTROL
ARCHITECUENGINEER: LIC NO, ADDRESS ��� e l ❑
CONTACT: Y t Qpg PHONE: dn�l-".'' = t BUILDING PERMIT INFO
J t I, 11w O�'r1' ' ^� QTY. .- EI.ECfR[C PERMIT FEC
4.1a-0 PLII.V,-s,/4/7e ez �S' �.g 17—`Xv 'f , BDG ELECT PLUMB MECH
PERMIT ISSUANCE Pue
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL I )OB OPSCRIPI'`ON
pKZ I hembyaffirre that l ae licensed under provisionsof Chaprer9m
(comenciagwith J
P00 Section 7000)af Division 3 ofthe Business and Professions Code.and my license is in PANELS
W"1IF—.. full force and effect.
IQ„ZW Liccnx Class Lie. UPTOMAMPS
may Dam cnmri ; : Y '. sitz 201.I"AMPS !J I'LB Wf a-
ZEOv=miZ. ARCHITECT'S DECLARATION OVER IpOpAM SQ.FT.FLOOR AREA $/SQ.FT.
OZ-0 I uademend myplanshall beused as public WOMB.
m
Cw SIGNS E-0:
���d�'J Licensed Professional
K
ad OWNER-BUILDER DECLARATION �51'Fr1Ati QR /MI
kOa V I hereby affirm that 1 um exempt from the Connector's License Low for the
w 31z)r following rescan.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER POLE INST.
u' which ieyuires a peunm to construct,atter,improve,demolish.or repair any structure
f ry prion.its BBmdcc,mBu requires the applicant paradedPermit,Permit,.file..igaed saemem POWER DEVICES
yWj(1<0 that he is licensed pursuant to the provisions of the Conoactoes License Low(Chapter -
a0.o�' 9(commencing with Section 7000) 4) :,on, fthe Business end Profesxione Code) SWIMMING POOL ELECTRIC �V^ALUAfTION.r-.�
wpm or thatheisenempt therefromand th ovsfa IlegMexemption.Anyviolation of OUTLETS-SWITCHES.FIXTURES C J �,J .✓V
Y Section 7031.5 by any npplicuil fora en it j 11,
the applicennoaclvil penalty of
O not mora jdrcA Jollare($ 111) NEW RESIDENTIAL ELECDR 5 .Irl'.11 ❑ I,eso r r y acs th ns wlecnmpensatian, Q S'T'ORIES TYPE CONSTRUCTION
wllldo the pact nendM nnfl' 0 Sm.7M4,Buelnoeabe Cantru9no's 1 cru Lu 1 a lytoanownerof
nmrnveD++her� drllsnchsrnselforthmughhls (ICC.GROUP RF.S.UNITS
etl the sn�l'CdoM4 ore nm imendcd orolfered fnnale.If, - -
huwever.the buildingar ia,mve�srrh�� sold within one year.fcompledon.the owner' 'DOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
❑ I,as ownerofthe propeny.umexclusivelycontracting with licensed contractors to QTY' PLUMBING PERMIT PF,Ii FLOOD ZONE APN
construct the project(Scat]044,Business and Professions Cade)The Conueanr'a PERMIT ISSUANCE
License Luw docs not apply mon owner M propeny who huihb or improves thereon,and
whocontmas farsuch projects with a contractor(.)licensed pummnuo the Contracture
License I.uw. ALTER-DRAIN&VENT.WATER(PA) FE.13 SUMMARY
❑ I am accept under Sec. B&PC for this recon BACK FLOW PROTECT.DEVICE �.S
SANITARY Y N
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND, SCtIt3OLTAX Y"• N❑ I hexbyaffinn that l haveacetificmeofeonxnno self-insure.aracertific.se of RECEIPT#
Writers'Compensation Insurance orecmifiMropy Oereof(Sa.3g0o,Lab CJFlXTURES-PER TR#which PARK FEE Y
covers all employee's u der this Nmhit RECEIPI'#
Polic p 1 TP( Z S GAS-EA.SYSTEM 1 C.4 ITfL
y � BUILDING DIVISION FEES
Company `LL CJ GAS-EA.SYSTEM V R4 I PIANCHECK FEE
a Cenifod copy is hereby futniahed.
❑ Certified copy is IBM with the city inspection division. GRFA S I
WAVINTEICEANt GRADING FEB
CERTIFICATE OF HXEMPDON FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed Bible permit is fortune hundreddollan(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE -
or less.)
I certify that in the performance ofthe work forwhich this pernin is issued,)shall WATER HEATER W/VENT/ELECI'R
oat employ any peraon in any manner sat as t.become subject at the Worked PAID
ZCompensationl2Waof Cidiforam. Date WATER SYSTENUTREATING Date Receiptp
Applicant
Z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,youshauld NEW RESIDENTIAL PLMB. SQ.FT. TAL:
rte.., become subject to the Workers Compensation provision ofthe Labor Code,you must
� > forthwith comply witheuch pmvBuma or this pcmrit.hall he deemed Walter. BUILDING FEE
a5 CONSTRUCTION LENDING AGENCY SEISMIC FEE
ZIherebyoffirmth,hend is a construction lending.gency for the pcifarmarreaf
V O the work for which this permit is issued(See,307,Civ.C.) TOTAL: ELECTRIC FEU
LTy 1r Lender's Name
F' Lenders Address QTY. MECIIANICAL PERMIT FEE PLUMBING FEE
V I certify that I have read this application and state that the above information is -
hg's 0. c.rrccl.I agree to comply with all city and county ordinances and stale laws relating to PF.RMITISSUANCB MECI IAN CAL FEE
On building construction,and hereby authorize mprexmatives of this city to enter upon the CONS'IRUC'DION'DAX
U 7 aMwe-mentioned properly for inspection purposes. ALTF,RORADDTOMECH.
Fl (We).gree to save,indemnify and keep harmless the City of Cupenium against
limbi litunjudgmems.cosh anti expenses which may in any way accrue against said City AIR HANDLING UNI OIQ CFyj
in consequents of the granting of this permit.
' I AIR HANDLING UNIj(AVEg/0,ffjCjMrw
Signamrcof Appllcant/Contrador Date EXHAUST 1100 U PAID ` r� 04'I
HAZARDOUS MATERIALS DISCLOSURE HEATING UMT(T 0,040 BTU) !s D Receipt#
Will the applicant or future building occup.nt store or handle hazardma material HEATING UNIT(OVER 1W,000 BTU) ti//< < _
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Ir
Cale,Section 25532(e)'f
❑Yea FNo VENTILATION FAN(SINGLE, RESIDI
Will theapplicantar(arum builJingoccuumx m
pseeyuipmcardevittBOILER-COMP UHP OR 1W,1100 BTU) ISSUANDATE
s whichcmit Y(J
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER[00,0010 BTU)
•District?
❑Vcs No NEW RESIDENTIAL MECH. SQ.FI'.
I have trail the hazallous amedala teyoomb nn under Chapter&95 of the
California Health&Safety Cede.Seetions 25505,25533 and 25534. 1 understand Nm
on,u buil0ing Jms nm bunts w have a must
be that it is to responsibility to notify the
cecupunt a!the mems whish must be mm prior to iuuantt of a Ccnificnt of
Occupancy. e1.
o J
Owner or authorize .gem One TOTAL: ISSUED BY:
OFFICE