26060 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF BUILDING-ELECTRIAL
CUPESIO NO APPLICATION/PERMIT PLUMBING-MECHANICAL PERMIT NO. 26060
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUI(I.yDIN 4/ 1)REg11S�: ,f� L (�- SANITARY NO. APPLICATIONSUBMITTALDATE
O 6M NV hh�' "�^+n'� UNIT# LOT 2��ISr��JJ
OWN SNAM PIIONE: CO R CTOR'SNAME - LIC NO:
nn� S' N/C CONTROL#
ARCHITECgENGINEER: LIC NO: AD ESS: DK 445 ❑
CONTACT: PHONE:
I�••s p, I 7APPLIAN7CES-
RIC PERMIT PEE HDR.DING PERMIT INFO
'. BDG EL PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION DENTIAL fQwz I hereby affirmfiat l am licensed under provisions ofChapter 9(commencing with CRIPTION
-�O Section]000)of Dlvlsion3of the Business and Rofaseions Code,and mylicenee is In
UU full force and effect.
FZ' License Cl�s�S�7''��—Lie# UPT02WAMPS
N5oi Date 1 Cantrectm . 201-I0M AMPS
F m 77. I ARCHITECTS DECLARATION
OQ ,OSQ.FT.FLOOR AREA $/SQ.IT.
ZN000 AMPS I understand my plans shall be used os public records. OVER 1
p¢N„� Y,1 Lmensed Rofesstonul SIGNS ELECTRICAL LED
�A
pFy �< OWNER-BUILDER
empt food
DECLARATION SPECIAL CIRCUIT/MISC. „ �� (� 7I' B��
{113 aF 1 hereby affirm rho[I am exempt from the Contraction's Co License Law for the
R m following reason(Scotian]031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
ce 5 which requires.wr nil a construct,alcor,improve,demmisb,or repair any mmum, ��
a2 prior to its issuance.alsoregmrw theapplicant Frascati permit to file.signed atatemem POWER DEVICES
W Q p that he is licensed pursuant the provisions of the Contractors License Lnw(Chapter
p'xaxo�' 9(wnuneocing with Section 7000)of Division Sof the Business and Professions Code) SWIMMING POOL ELECTRIC --VALUATION
sal—m or that he is exempt therefrom and the basis for the alleged exemption.Any violation of n
N Section]031.5 by any applicant for epermit subjects the applicant ecivil penalty of OUTLETS-SWITCHES-FIXTURES
6 not more than five hundred dollars($500).
161
❑ I,usownerofthepropenyormyemployeeswifiwages esrheirsolecompensa[ion, NEW RESIDENTIAL ELECTR _SQ.FT. STORIES TYPE.CONSTRUCTION
per, will do the work,andthe structure is not inandedorofferW for sale(Sec.704F,Business
and Professions Cade:The Comecon's License Law does not apply m an owner of /
Property whobuiIdsorim naves thereon,andwhodoes such work himself trthrough his
wnemployees,providedthat such impeovememsare not intendetorofferedforsale.If, OCC.GROUP RES.UNITS
however,the building or improvement is sold within one year of completion,the owner.
builder wil I have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,as ownerofthe property,am exclusively contracting with licensedcontracters to QTY. PLUM13ING PERMIT FEE FLOOD ZONE ARN
construct the project(Sea]044,Business and Professions Code:)The Contractor's
License Law doesnot apply loan ownerofproperty who builds or impmvestherconand PERMITISSUANCE
License Law.
Laww..aforsuch projects with aconvactor(s)licensedpursuant[m[he Convaclols
ALTER-DRAIN&VENT-WATER(E.4J FEE SUMMARY
❑ I nm exempt under Sec. ,B&P C far[his reason BACK FLOW PROTECT.DEVICE - OUTSID FEES
OwnerSANITARY Y—N
—
WORKMAN
DRAINS-FLOOR,ROOF.AREA,COED. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ IM1ereby affirm that)haveucenificaa of cmnsenno self-insure,or a certificate of FIXTURES-PER TRAP - RECEIPT#
Workers'Compensationlnsuranceoracenifiedcopythemof(Sec.3800,Lab C.)which PARK FF.E Y N
avers ellempin and, I isge��.yys� 1 GAS-EA.SYSTEM- INC. OUTLETS RECEIPT#
Policy#_Ili.—Y Y BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER4(EA) PLANCHECK FEF.
❑ Certified copy is hereby furnished. 72�Gr
�Ccnified copy is fled with the city inspection division. GRFASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need notbe complead lfthe permit is fmooe handled do][.($IW)
to less.) SEWER-SANITARY-STORM BA.200FT. ENERGY FEE
I cenify that in the perfomancemf thework for whJ'Glrthis Permit is issued,I shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so u toyCcome subject a the Workers' PAID
,7. Compensation Luws of Califnmie. Dam WATER SYSTEALTREATING Dr. Receipt#
Applicant
C, NOTICE TO APPLICANT:If,after alfing this Contrasts of Exemption,you should NEW RESIDENTIAL PLMB. SQ,PT. TOTAL:
(~ V) become subject to the Worker's Compensation provisions of the Labor Code.you must
aH forthwith comply with such provisions or this permit shall hee deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AD I Y SEISMIC FEE
1 hereby affirm dol is i wnstruaion lends agency for the perfomwnce of
U O the work for which this permit is issued(Sec.30 , iv.C.) TOTAL: ELECTRIC FEE
W Lender's Name
C U Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
W I certify Iha[I have read this application and state that the above information is
correct.l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
�. Cn building construction,and hereby atdlwcze representatives ofth{s city to enter upon the
U Z .hove-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree jo save,indemnify and keep huntress the City of Cupertino against
liabilities,judgmenrs,costs and expanses which may in any way accrue agance,alid City AIR HANDLING UNIT(TO 10,000 CFM)
queoce of the grisIt,ng of thispermit.
1 AIR HANDLING UNIT(OVER 10,000 CFM)
gnamreof bcam/Conrmcmr Iata� EXHAUST HOOD(W/DUC)
PAID
HAZARDOUS MATERIALSDISCLOSUREHEATING UNIT(TO 100,0000TU) Date Receipt#
Will the applicant
helia ar infurore building occupant store or and
Health a mmedal
as defiSetl by the Cupertino Municipal Cade,Chapter 9.12,end the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code,Section 25532(a)]
❑Yes NkNo VENTILATION FAN(SINGLE RESID)
Will air co imntorfm as building bythemuse Area
Quality whichemit
BOILER-COMP(3HP OR I OO,WO BTU) ISSUANCE DATE
•hazardous air communists as defined by the Bey Area Air Quality Management BOILER-COME(OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ.District? 4 1 D
❑Yes No FT.
1 have rend tha bazmdous materials requirements under Chapter 6.95 of the p r�
iflebuil Hgdoes Safety
hvea tens nant,
it is my responnd sibility
Iunderstanditytontif that Ifb "'w' 11
ifth,surn of
snot currentlyaswhihmustnbe met ror myssuanc siof tonotifyOne 91 A
o hem of the Ly,irements which must be met prior to issuance of a Ce17'fca[e of �/Y v �f
Oc cy ,C /'`QL f�JrS(' 7T/C1J r
Owns authonzed agent Date TOTAL: ISSUED BY
OFFICE