26563 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOr'"
h'D ' ' TERM[ NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL Ce C C O
BUILDING DIVISION ISUILDINGPROJECI'IDENTIFICATION o J v J
BUILDINGADDRESS: / (` —Z/// SANITARY NO. APPLICATION SSUUIOTTI1'AL DA11
f I%) & / V r� �{`'�L lHG(OUNIT# furl,
OW ERS AME: PHONE: CO CI'OR'S NA LIC NO: OL L
N/C CONTROLp
ARCHITEC'UHNGINCER: LIDNO: ADDRESS: ❑
CONTACT: PHONE: }; s `'2 "/ BUILDING PERMIT INFO
QTjY �LL ,IZC PERMIT,' -.FEE
BLDG ELECT PLUMB MF.CH
PERMIT ISSUANCE El 0
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL �_�w�\ sossw¢C I
awz I hereby affirm that l am licensed underprovisionsor Chapter9(commencingwith - —� I /'
1700❑ Seaton lOW)ofDivirion 3ofthe Business and Professions Code,and my license is in PANELS
1<,U full nsee lass effect. /k ,� �a'
=Q WE full frc Class Lick UP T0200 AMPS `/�V,T/1f 1\+
m6y Date Contractor 201-INXIAMPS
FD ARCLID'F.CT'S DECLARATION SQ.FT.FLOOR AREA 3/SQ.FT.
Z O til" I understand my plans shall be uud as public emoNe. OVER 1000 AMPS
y F Q SIGNS ELECTRICAL
MQ '1 Licensed Professional
YY < OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC. /
E�LdOa0 I hcrcby ufBrm Nm I am exempt from the Comrannr's License Law for the /T 1ppI Ih[.�
u13 f I— following mason.(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST. I j C I '' ` I':" I� II nY4� 1
h�0a which reyvimx a permit m con.mrva,alter,improve,demolish,or repair any swetum l' I; II y
}, to its issuance,aim the applicant forsuch Permit file irrigated statement POWER DEVICES
Prior legatos pp palmi gn 1 I r J
W Na0 that he is licensed pwsuunt to the provisions of the Comenctors License Law(chapter k I I I� I I+•-• I'—J
X.y. SWIMMING POOL ELECTRIC
e.C 9(commencing with Section of Division 3 tribe Business and Pmfewioas Cod<) l<
WMro or that he is exempt herefrom and the basis for the alleged exemption.Any violation FIXTURES of OUTLETS-SWITCHES. DATE
FZQ Sadism 7031.5 by any applicantforapermil,.bjml,thenpplicanno a civil penalty of
FSS nm Nfiwe hund
un Evred dollars 0).
(8500). NEW RESIDENTIAL ELECTR _SQ.I STORIES I'. '.CONSTRUCTION
C_Fp 1 sth HM1epropeny,mmyeswith wngesasthciuolecomperssauon,
a3=° an Jmhcwons Code:ehe Cumiater's License
Law
not
apply TLW. weir of
and 'mfcxsinns Cale:The Commaor's License taw docs roe apply to an owner of
property who builds or improves themon,and who duessuch work Nmulf or through his
employees,provided that such imprtvemen¢arenot intendcdoroffercd forsale.If. OCC GROUT' RES.UNI'T'S
however,the buildingtr improvement is sold within oneyear ofcompletitn,the owner- TOTAL:
builder will have the burden of proving thin fie did not build or improve fur purpose of
"ale')' QTY. .. - PLUMBING PERMIT' FEE
❑ I,ax owner of the OmpertY•umcaduxively. ctmrneeing with licensed contractors to - ROOD ANN
construct the project(Sec.7044,Business and Professions Code:)The Contractor's
License Lawmia not apply manownerol'pmparty whobuildsorimproves Nereon,nnd PERMITISSUANCE
n
who contracts for such projects with u contraorD)licensed pursuant m the Contracrors
License Law. ALTER-DRAIN&VENT-WATER(LA) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C fill Nix reason BACK PLOW PROTECT.DEVICE (SIDE FLITS
SANITARY Y N
Owner Dam DRAINS-FI-00R,ROOF.AREA,COND, RECIiIPI'p
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ I hereby infill that[have a certlficmc ofconsent to self-insure.or a certificate of FlXTUREB-ERR TRAP RECEIPT%
Workers'Compensation insurance or a certified copy thereof(Sm.3800,Lab C.)which PARK FEE Y N
cs all employee's under his permit. GAS-EA.SYSTEM-1 INC.4 0UTLETS RECEIPT 0
Policy X BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cenificd copy is hereby famished.
❑ Certified copy is Bled with the city inspection division. GREASEANDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATC OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thissection amid not becompleted Russ Permit is for tate hundred dollars($100f SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
rales")
I terrify that in the performance of the work for which this Permit is issued.I shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so u to become subject to the Worker' PAID
Ctmpensatinn[awstf C.ifomia. Date WATER SYSTEM/TREATING Date Receipt#
O z Applicant
z Q NOTICE TO APPLICANT:If,efree making this Cenificatcof Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
F-' y become subject to the Workers Compensation provisions ofthe labor Code.you must
� , forthwith comply with such Pnwisions or this pnmitshall Ine deemed revoked. BUILDING THE
6i (] CONSTRUCTION LENDING AGENCY SHISMIC FEE
1 hereby affiant that there is a construction lending agency for the performance of
L z the work for which this permit is issued(Sm.3097,Civ.CJ T ELECTRIC FEE
lcnder's Name -
u" (•" Lcoderx Address QTY: MECHANICAL PERMIT' FEE PLUMBING FEE
U 1 testify that 1 have teed d sanhat the i
this epplirminn ante te above nfnnnation is - M17CHANICAL FEE
>4 W correct. 1 agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
F-' CCI�) building mosntcelon,and hereby authorize representatives ofthis city to enter ripen the CONSTRUCTION TAX
Uz a base mentioned property for inspection purfmaea. ALTER OR ADD TO MECH.
(Wc), rc m.xavc,iuJcmniI and keep hmtnlyyyxs it c City of Cupertino nguinst
liabilities., melts.costs atW<apenua which mevM anywayaceruengamaraid City AIR HANDLING UNR(TO 10,000CFM)
yu dth finein6 of ix elate. j JI ti:�
AIR HANDLING UNIT(OVER 10.000 CFM)
Sig amren pphc VComracusr Dat EXHAUST FOOD ONMUCq ^ PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Dam Receipt al
Will the applicant or future building occupant store or handle hmarduos material HEATING UNIT(OVER 100,000 BTU) IOTA[-:
as defined by the Cupcstinn Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)?
❑Ycs ❑No VENTILATION FAN(SINGLE RFSID) M ---i
ISSUANCE DATE
Wilhheupplicamorfmumbuildir9MCupme use eyuipmemordevicc which emit BOILER-COMP(3111'OR 100,000 BTU)
hazardous air mentereares as defimal by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) P '` D
District/
❑Yes ❑No NEW RESIDENTIAL.MECIL SQ,IT.
I have read the hazandous materials requirements under Chapter 6.95 of the JUN 17
1994
Culitomia Ilcalth&Safety Coda Sections 8505,25533 and 25534. 1 understand Nat /s
it the building docs not'remedy haven tenure,that it is my rexlnmm C
xibiliey mtily the I
occupant or the aqulr mems which most be met pine to issuance of is Certificate of I.UrCIY 1 HV(X
fxcapamy.
Owner ur authorized ir,nt Date TOTAL: ISSUED BY:
OFFICE