26214 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDIN -EL. TRI A. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJEMADENTIFICATIOry 26214.
BUILDING ADDRESS. _�s �� SANITARY NO. APPLICA�TIIONSUBMITTALDATE
J 6 �J D ''JyC,-
• UNITar LOTH
sPc
ijll
OWNERS NAME: OC NTL
PRm' R
60= nCeCeaNi NIC CONTROL#
• RCHI'IT?Cf/IiNGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
So am FLd FS 3 79—d'200 BL G MECH
PERMIT ISSUANCE �.•
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL •+I + \ l�D DESCRIPTION
pyZ Ihemby affirm that em licensed underOrovisionsofChapmr9(commencing with
W00 Swum 90W)of Division 3 of the Business and Professions Cade,and my license is in PANELS 1
K,_1.. full foroe and effect.
-EZu Liccnuv 8 Lic.N a UP T0200 AMPS
y[—G Date' 3 A_5 r4 Cmadw a 201-IM AMPS
ZOr`°irZ ARCHITECTS DECLARATION S'O£CCe ZeSI OVER 1000 AMPS SQ,FT.FLOOR AREA SISQ.FW.
O Z—p 1 understand my plans shall be used as public records. �-
SIGNS ELECTRICAL
LicenxJ Professional u V
CC OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
p, 1 hereby affirm Ihal 1 emexempt from the Contractors License Law for the
tvl3ln following reason.(Section]031.5.Business and Professions Code:Any city s county TEMP.METER OR POLE INST. J
17 00 which requires a permit to construct,alter,improve.demolish,or repair any structure c
4p tsN¢� prior to its issuance,alsorequires the applicant for such permit to fleasigMrmement POWER DEVICESDATE
L
A C p O that he is licensed pursuant to the provisions of the Conwaor's License Law(Chapter
aaxo� 9(commcmingwith Section Tl00)ofDivision3ofthe Businwsand Profbssions Code) SWIMMING POOL ELE O- J VALUATI
W�H or shot he is exempt theremarn it the basis for thealleged exemption.Anyviola,imof ��
b-ZG Section 9031.5 by any applicant for a Permit subjects the applicanuaacivil Pendry of Ot1T1E1'S-SWITCHES-DXTURFS �Gee,
not morcthanfivehawrcddo.ormyempl NEWRESIDENTIALEI.Em _SQ.FT. STORIES TYPF.CONSTRUCIION
C�p ❑ Lasawr to,.he n arm em to tts withw thcirsolecam tion,
Prope Y• Y t Y agesas Penna
a3� will dothewonsCdthe he Conttructure actotinxndese Law
rdoes ntapSea.704,L Business
and Professions Cade:The Contractor's Lignac Law does not apply to an owner of
property who bu i Ids ar improves Hereon,and who dean such work hi mse I f or through his
employees,providedthatsuchimprovementsamnotintendcdoroffendforsele.If, OCC.GROUP RES.UNITS
however,theluddi ing or improvement is sold within one year of completion,the owner.
builder will have the burden of proving that he did not build cr improve for purpose of
sale.).
❑ I.mowner ofthe property,em exclusively contracting withluensed conmactosm QTY. PLUMBING PERMIT FEE FLOOD ZONE. APN
instruct the project(Sec.9044,Business odd Professions CWeU The Commcmr'e
License Law dreams apply Loon ownerofpropeny whobuildsorimproves thereon,and J, PERMIT ISSUANCE
who contracts for such projects with a conductor(c)licensed pursuant to Ore Coneracm/s
License Law. ALTER-DRAIN&VENT-WATER(RA) FEE SUMMARY
❑ 1 am exempt it,Sec. ,B&P C for this teaam BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,ARFA,COND. SCHOOLTAX Y N
• ❑ Ihereby affirm that l have a certificate ofemxnuo self-insure,or a cenificare of FIXTURES-PER TRAP RECEIPT#
Workers'Compensation Insurance ora certified copy thereof(Sec.3800,Lab C.)which 3iiii I PARK FEE Y N
covers all employee's under this permit. GAS-P.A.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
ZV Caddied copy is fled with the city inspection division. GREASE(INDUSIRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION PROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe,permit is foronehundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
mless.)
I certifydru m don performereeofthe work for which this From,is issued,Ishan WATER HEATER W/VENT/P.LECTR
not employ any person in any manner sou to become subject to the Workers' PAID
Compensationlswsof Califomia. Do¢ WATER SYSTEWDEATING Date Rai#
O z Applicant
0 NOTICE TO APPLICANT:If,after making this Cenifica ,of Exemption.you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
In become subject to the Workers Compensation previsions of the Labs Code,you must
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE saaak
kll
� p
CONSTRUCTION ECHOING AGENCY SEISMIC FEE O
V z I hereby dPom that there is a construction lending agency for the performance of .
the work far which this permit is mss eat gre.309],Civ.CJ I' ELECTRIC
IL FEeZJl
r lenders Name PLUMBING FEE
Lewers Address QTY. MECHANICAL PERMIT FEE
U
0. tio1 certify that I have read this applican ane ab
d sure that Ne information is FE
MECHANICAL E
correct. l agree to comply with dl city sand county ordinances and state laws relating to PERMIT ISSUANCE
F-' building conswction,and hereby authorize representatives ofthis city menterupon the CONSTRUCTION TAX
U z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and kap harmless the City of Cupertino against
Iiuban i lies,judgments,costs and expenses which may in my way accrue agaimt said City AIR HANDLING UNIT(TO 10,000 CFM)
yucnce of the
morning ofthis pemtit. 3 ^3S^',=) PIR HANDLING UNIT(OVER 10.000 CFM)
ore of ApplicanVCommartor M— Date EXHAUST HOED(WIDUCO PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,0110 BTU) Date Reeelpt#
Will the ee Cupertinont or ure bdal Code.Cng hapstoreter 9.12.
or hurdle Heandous lth and Safety HEATING UNIT(OVER 100.1100 BTU) TOTAL:
mal
as defined by Ilse Cupertino Municipal Code,Chapter 9.12,anti the Health and Safety
Gqh.Section
Yu ❑No 25532(e)?
❑ VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
Will theapplicantorfusrebuildingoccupamux<quipmemmdevicnwhichcmit BOILER-COMP PHP OR 100,0011 BTU) P � ' D
hasmdous umia
air conmis as rea defined by the Bay AAir Quality Management BOILER-COW(OVER 100,000 BTU)
District?
El yes El No NEW RESIDENTIAL MECH.—SQ.FT. WAR g�Q0 1994
I have read the hanxiduas meterids requirements under Chapter 6.95 of the n
Caffomia Health&Safety Code.Sections 25505,25533 and 25534.1 understand Net
Irma building does not currently have a tenant,that it is my responsibility to notify the T C�IY
Ur L'u"
occupant of I ements which must M met prior to issuance of a Certifician of
Occupancy. ?-3 . ,
^.S d ')�
Owner or milhndr gent Data^ 1 TOTAL: ISSUED BY: SIM
OFFICE