26442 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY r,
CITY OF CUPERT[NOIS UILDINUA. PERMITNO.
BUILDING DIVISION APPLICATION/FERMIT PLUMBING.MECHANICAL 26442
BUILDING ADDRESS: BUILDING PRO�JEC'TIDENTIFICA1'ION n v 4 4 n
aD / 3 1rWI0 / fO� u0ICA,
SAN]'TARY NO, APPLICATIONSUBMITTALDATE
UNIT# LOT# CA72,
OWNERS NAME: PHONE: CONTRACI'OR'SNAME: 1 1 Iist"4,AJyJ.ICNO:
NIC CONTROLp
•ARCHITECT/I:NGINEIR: !w LICNO: ADDRESS
1 / ❑
CONTACT 1 o1 (Y SO LONE: V,16) QTY. ELECTRIC PERMIT PEG BUILDING PERMIT INFO
//IQ Hq ��.-;Vqp BLDG ELECT PLUMB MECII
PJ PERMIT ISSUANCE - 97 � El 11
NW LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL Id'
p y.Z Iherebyeffirm Nat lam licermadmiderprovisionaofautdar9(c.mmencing with �/ / lOB DESCRIPTION Ys�9
woo Section 7")of Division 7 of the Business and Professions Code,and my license is in PANELS II aG� vDs.J/M,d/Jf, AMJP
tyUF-- fail force end effectLicay _ 1
,Fir?y PS
zw
Datense Clas —�ke
III 1!111� ContrectnZ � O
IBITItMp AMPS q#�'
ZOv Z ARCHITECTS DECLARATION OVER 1000 AMP S .Fri.FLOOR AREA $lgQ.FT.
O Z_ I underswnd my plans shall be used as public records.
FIFE - SPGNSELECfRI L
Q,j,�'� Licensed Professional
E5,w OWNER-9UIIAER DECLARATION SPECIALCIRC I C.
JJecS5,,O,U ' 1 hereby affirm that I am exempt from the Contractor's License Low for the
following reason.(Section 7031.5,Business and Profeolons Code:Any city or county TEMP.METER EI T.
which requires a gamut to consumer,alter,improve,demolish,or mpair any stmaure
Ny p-2 prior to its issuance,also requires the applicant forsuch Permit rile a signed statement POWER DEVICES
aC�p
that he is liccmed pursuanlm he provisions of the Contractor's l.iceme Law(Chapter
p 9(commencing with Section7")o'Division 3 aline Business and Professions Code) SWIMMING POOL ELECTRIC ,{/ q VALUATION L I VCM
,.,y or that he is exempttherefromund the hasisfor rheulieged exemption.Anyvlolotionof OUTLETS-SWITCHES-FIXTURES �'{ l f ALU HiQ 9
FZQ, Section]03 LS by any applinint furnpemtit sobjenv the upplicunnn euivil penalty of ) Kpo
5� 0 not more Chun five huMrcd dollars($500). NEW RESIDENTIAL ELF,CTk 5 .FT.
❑ I,usowncmfthc property,ormyemployees with wagesas Neirsnlcrompenswion, Q STORIES TYPECONS'IRUCTION
a will do the work,and thestmctum is not mandedoroflbrcd basalt,(Sm.7044,Business 1
and Professions Cole:The Contrucmrs License Law does not apply to an owner of
property whobuildsoriniprovex thereon,and whodoes such work himselforthroughhis
own employees,provided that such imprnvemcrosure no ntendM.roffered forsele.If, OCC.GROUP HES.UNITS
however,the building.,improvement is.+old withinma,ar.fcnmpletion,them,mer- TOTAL:
builder will have 0te burden of proving Nut he did not build err improve for pugtose of
We.).
❑ I,as ownerofthcpmpeny,umexclusivelyamtmctingwithlicensed...tomposto QTY, PLUMBING PERMIT FEE I>LOOD LONE APN
construct the project(Sec.7044,Business and Professions Code)The Comon,ims PERMIT ISSUANCE
License Lnw does nm apply m on owner o(pmperty who huilJs m impmves Nercon,and
whocommets for such projects with acentracrogs)licensed pummuntmie Contractor'.+ ALTER Limmo,Law. FEF.SUMMARY
❑ 1 am exempt under Sm. B&P C for this revon BACK FLOW PROTECT,DEVICE. SID.FEES
SANITARY Y N
Owner pate RECF.1 p
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPF.NSA'I'ION DECLARATION SCHOOL TAX Y
xrI hemhy affrm that l hove a certificate of consentto self-insum,or a certificate of FIXTURES-PER TRAP RECII
kcrs'Compensation Insurance on certified copy thereof(Sm.JS00.Lab CJ which PARK FEE Y N
Polmsg(employ yup rt`pcnt�su� LDING DC:BIONFE
1�'IIIA q + GAS-EA.SYStEMII a0 .EI
Cmpany ha—y�I1 1 LP
GAS-EA.SYSTEM-O 4(JA) PLAN HECK F
Certified copy is hereby famished.
❑ Certified copy is filed wahine city inspection division. GREASEVINDUSTRLASVINTEk MR 'RACE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOUS
COMPENSATION INSURANCE
FMLJ
(This section need not be completed!fine permit is forms hundred dollar($TOB) SEWER-SANITARY-STORM HA.200FT. ;RG Ili
or less.
I certify that in the performance of the work 6r which this .oil is issued,ishan WATER HEATER W/VEN/ELECTR
not employ any permn in any manner so as to become subject to the Workers
Compensation Lawsof Califomia. Date WATER SYSTEM/IREATING Data Reci t#
C) z Applicant
z 2 NOTICE'I'O APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.Fri. TOTAL:
(q become subject to the Worker's Compensation provisions ufthe Labor Code,you must
5 forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING 193E
4 (] CONSTRUCTION LENDING AGENCY SEISMIC FEE '
Uz 1 hereby affirm(hut the.is a constmcti.n lending agency for the performance of TOTAL:
O Ne work for which this permit is issued(Sec.3097,Civ,C.
IIs Lender's Name PLUMBING FEE
Lender's Address QTY. MECHANICAL PERMIT FEE
V I certify the(I have rood this application and slate that the solve information is
se's C7a correct.I agree to comply with all city and county ordinances and state laws reletinm PERMIT ISSUANCE MF,CI IANICAI.FEE -
�' huilding construction,and hereby aullimire representatives of Nis city to enter upon the CONSTRUCTION TAX
U alvwe-mentioned property for inspection purposes. ALTER ORADDTO MECII.
(We)agree m save,indemnify unit keep h mird,sa the City of Cupertino against
Iimilities,judgmem.i.costs and expenses which may in any way accrue against said City AIR HANDLING UNIT TO 10,0(8)CFM)
in consequence of the grunting of this permit.
AIR HANDLING UNIT(OVER10 00 CI' )
Signature of Applicant/Contractor Data EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATIiN1A1.5 DISCLOSURE HGTING UNIT(TO 100, Dam Receipt#
Will the applicant or future building occupant tore or handle baaardous arsenal
asdefned by the Cupertino Municipal Code,Chapter9.12,and the health and Safety HEATING UNHTOVER I00,00)BTU) TOTAL:
Code,Section 5572(e)7
❑Yes No VENTILATION PAN(SINGLE RESID)
BOILER-COMP(3HP OR 100,1100 BTU) ISSUANCE DATE
Will Neapplicant orfumre building occulss^tuseequipmem mdeviccs whichemi( !1
0 hozadous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) R!'— 0
Distnn7
❑Yes 9N. NEW RESIDENTIAL MECII, SQ.FT, Jul Q
1 have read the hewdo e.materials mquiremrnta under Chapter understand
of the
Jul w
California in,lthde&Safely Code.Sections ant.that
5577 and 25574. I fry lama it that
. icupant of
"Ieraaurtcntlyh It most a that it is to responsibilityto notify Ne q7 Ur �V)J
occupant of the raga'emrnB which must be mer prior m iuuance of C rtHande of k
Occupancy. ' .
Owner or amhori gent Dare TOTAL: ISSUEDB
OFFICE