26682 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOIID:DEn2T-Rf,F'E� A. PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICALI'IO A
BUILDING DIVISION BUILDING PROJECT IDEV' FICATION Q L
BUILDING ADDRESS: SANITARY NO. APPLICATION SUHMITTAL DATE
OT 0 �`l�
OWNS AME: s PII N✓ CONTR O 'S NAME: LIEN ' l
ILC I JI3-103,5N/C CDNTRDLN
ARCH[IE ''/ENGINEER: INC AD F
CONTACT: PIIDNF.: BUILDING PERMIT INF
Q'I'Y. ELECTRIC PERMIT a FEE
^�17-757a, �(tLDCa EI.E❑CI' PLUMB ME❑CII
�aC/J5 PERMIT ISSUANCIi !�W_('
LICENSED CON'TRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOg QESGRIPTION
GCZ Thereby of
l am licenseJunio,and ProOmoion;C 9(commencingwiM �` '�
�d00 Section]000)of Division3of the Business and l4ofessionsC de.andmylicense is in PANELS {� •/l•�
ysuF
full e t 6 UP T021NIAMPS ��s
[a-ZW license CF s ec LI0.#
m,z Dae Camra Im 2o1-IOW AMPS
F'co ARCHITECTS DECLA SQ.IT.FLOOR AREA S/SQ.FT.
Z O m ]on rsmnd my plans shall be used as public reco s. OVER IOOO AMP$ / B
CZ-0
Fye; SIGNS ELECTRICAL
Licensed Professional
X C)W, OWNER-BUILDER from
m the ComTION SPECIAL CIRCUIT/MIS rV\i 1
jiOaU I hereby affirm the I am exempt(ram the Commet Co License Law for the
rl3 to m which inquires a (Section]1131.5,Husher,im rove.t P e o li h.or m music
city otractusandy TEMP.METER OR IK)L INS'I'.
F O-S which requires n permit to conswa,alma improve,demolish,or repvr any swcture E
h�7
prioro its issuance.also requiteth
s e applicantorsuch permit to file a signed statement POWER DEVICES PATE
W NP
C< that he is licensed pursuant to the provisions of the Commctors License Law(Chapter
YWo 9(eonrmcncing withSectinn 7000)ol Uivieinn30ftM1e Bminos and Rnfcsaloos Coda)
SWIMMING POOL ELE VALUATION
Pore—m .,,but he is escmpl thcrefren and the basis for thealleged exemption.Any violation Of /n^�
F-ZQ Section 7031.5 by any applicant to,.Nona subjects Ne°#,divan ma civil ponaltyid OUTLETS.SWITCHES-FIX RFS C;?00 x
fSp
net marc than five hundred dollars(S300). NEW RESIDENTIAL ELE R _SQ.FT. STORIES 'TPE YCONSI'RUCTDON
�, m ❑ I,asownernftheproperly,many employees with walmassiheirsole compensation,
S will Bothe work,and the structure is not intended oroffemd particle(See7044,Business
and Professions Cade:The Contractors License Law does not apply ho an owner of
property whobuildsorimprove,thercomand whodoes,anh work himself n througM1his
employees,provided that such improvementsarc not inteadedaroffercd forsale.IL C. .ROUP U
NITS
however,me building or improvement is sold within one year of completion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for propose of
side.). QTY. PLUMBING PERMIT FEE ooU'.ONI?
❑ I,us owner ol'Ihepmpedy,amexclusively cnnlracting wi0licensed nmwclncs as
onstmct the project(Sec.7014.Business and Professions Cale:)The Convectors
License lawdoes not applym anownerofpmpertywho builds m lmpmvexthemon,and PERMIT ISSUANC17
who contracts for such projects with a<onwctods)licensed pursuant m the Commcmr's
Liccnsc Law. ALTER-DRAIN&VENT-WATER(FA) PEIi SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK ROW PROTECT.DEVICE O SIDE ItFS
SANITARY YN
Owner Dam DRAINS-FLUOR,ROOF.AREA.COND. RECEIPT#
AR
WORKMAN COMPENSATION DECLA'T'ION SCHOOLq'AX Y N
❑ I herebyafframat[have a certificate ofemakenl to self-insure,or a certificate of FIXTURES-PER TRAP RECEIPTM
Works Compensation lasumnce or Tied copy therrof(See 3800.lack,C.)which PARK FEE Y N
casall employe td/i GAS-BA.SYSTF;M.1 INC.40UD. S RECEIIsI'p
Policy# �wI BUILDING DIVISION FEES
Company ,p/—fk�� 1 `Gm GAS-EA.SYSTEM-OVER 4(1A PLANCHECK FEE
❑rcedified copy ish e y mished.
Cedified copy is filed with the city inspection division. GREASUINDUSI RI.WASTE IiRCEPTOR GRADING ITE.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed lithe pemtit is forone hundred dollars(EIM) SEWER-SANITARY- ORM FA.20017. ENERGY FRE
or less.)
Icedify that in perfo the alk for which lhispermitis'sued, hall WATER HEATER FNT/ELECR
nm employ nny as m become subje o PAID
Cnmponsa' n T WATER SYSTE BEATING Dam Receipt p
O z ppplicam
z0 NOTICE TO AP TAME:if.afire mg Certificate of Exemption,you should NEW RESTDP PAI.PLOB. SQ.FT. TOTAL:
(•' to
face
ome subject m N Workers Cot pe ver s ons of the Labor Code,you must
� ? fonhwithcomplywithsucliprovisi sr thispermitmshallbeckemedrev.ked. BUILDING ITT;
0. QCONSTRUCTION LENDING AGENCY SEISMIC FEE
7 Z I hereby affiw that there is a construction lending agency for the performance of
L) O Ihework for which this permit is issued(See 3097.Civ.CJ 'TOTAL: ELECTRIC ME
Lender's Name PLUMBING FEE
F Lender's Address QTY. MECHANICAL PERMIT FEE
V I certify that I have mad this application and scam that the above information is MECHANICAL.FEE
correct.l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
I-^ nj building construction,and hereby authnriee repremamoveso(this city to enter upon the CONSTRUCTION TAX
L.) z alawe-anentional property for inspection Imposes. ALTER OR ADD TO MECH.
(Wc)arme t save,ademmfy and lumdess the City of Capemno against
liuhilitias,judg c scows expenses hich sty in any wayaccmeagniasaid Cly AIR HANDLING UNIT(TO 10,000 CFM)
comcyuene a hegmnr of ml mit
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of pl can nmmctor Date EXHAUST HOOD OODUCF) PAID
HA DOUS.IAT IA ISCLOSURE HEATING UNIT(TO 100,0(00 BTU) Uam Receipt#
Will the applicant or future buil ' cupatnsmreorhandlehavrdetsmamrial HEATING UNIT(OVER IW,INN) U) TO
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Care,Section 2553200) VENTILATION FAN(SING L' EMD)
❑Yes ❑No ISSUANCE DATE
Will IM1e npplir mnrlumrcbuildingtecupan useequipmrnmrdevias which,rad BOILER-COMP(31IPQ IW,llfl(1 BTU) p�
h:vunlous air contaminants as defined by the Bay Area Air Quality Management BOILERR-COMP(O IM."BTU) 4"
District? sf
11 Yea ❑No NEW RESIDE I,MECH. SQ.FT. n
I have mad the haruraus materials nermicmcrns under CM1apmr JUY -I 6.95 of the rsl 4 sL 9 1994
Califom25
io Health&Safety Code.Sections 505.25533 and 25534. I understand door M
if Re building mea ma currently have a tenant that it is my responsibility to notify the Ur {,Ur
eupanl of the requircmems which must he met prior to issuance of a Certificate of f
Occupancy. G
Owner or authorized agent Da¢ TOTAL: ISSUED BY:
OFFICE