26018 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINOITlrl.nIN U—F-1..1—CIII I.A1, PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 26018_
BUILDING PROJECT IDENI'IFECA'1
" -INNS
BUILDING ADDRESS: SANITARY NO. AP1PLICATRINN SUBMIT"ITAI,DATE
UNIT# LOT# 1 —�`fy�
OWNPiWAMf?: PHONE: CONTRA 'ORBNAME LIC NO: V'� v 1.
// ,r NEC CONTROL
aRCE11'I1?C'1'/HNOINhiR: LIC NO: AD[R S����� �� z•SCt
CONTACT: PHONE: yJ
QTY. ELECTRIC PERMIT FIiE Bl11LDING PERMIT INFO
1e 3y -91x93 PERMIT ISSUANCE B G PLUME MECII
❑ ❑
LICENSED CONI RACIOR'S DECLARATION APPLIANCES-RESFDENTAI,
t]KZ Eherehyaff nthatlam licensed underprovisiorsom Chapman?mmemencingwith JOB DESCRIPTION
1100C Section 70W)of Division 3 of the Business and Professions Code,and my license is in PANELS
FF�-UF full force and ettc
ZW License Clas.• Lip.It �J G/� w i /r UP T02W AMPS
y6d me Commcmr_fQ^.]-yCLO 201-TIM AMPS
ZO'� 5 IT..FLOOR AREA $ ET.
y'= ARCill be u'PS DBCLARATION - OVL'R IOW AMPS Q' y
OZ—G InnclersumA my plans shall be nseA ns public rtcnnls'
`n SIGNS ELECTRICAL
KKQ Licensed rrofoeaonw
tyKQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XOatJ I hereby offirin(Se that I am exempt from the Cosions Cs License Law for the
41��t1ii
fullmvirt, Businusand Professions Code:Any city nrccture l'1?MP.ME]'ER OR POLE INST.
F'•mJ which requires n permit re construct,aper,improve,demarm t m repair any structure
act
fact he slicenmmnalso rnt totsthevisiosocant f r suchthe Co perrNus filLicense
ned Law
POWER DEVICES
C G p that he is licensed with
Sec or
the provisions of the Commaols License law(Chapter
c. ca 9(Cennnenaing whh Soetien]OW)n[Division3ofthe Business and professions GUE) SWIMMING POOL ELECTRIC OO
W�h a,that he is excmpuhclefmmand the bids fordmidliegW exemption Any vodiummauf OVII ITIS-SWITCHES-FI%TLRIS
P'ZdSection 7031.5 by anyapplicanl fora permit subjects tha npplicnnnoe civil pamltyof
Wss not more than five hundred dollars WWI.
, ❑ LasownernfNCPmpeny.prmyemplDyecswithwagesastheiraolecompensatins NEW RFSIDEMIIAF.ELBCIR _SQ.FT. STORIES 'IYPP.CONSTRUCI'ION
y3?.a will clothe work,and the structure is notitnended predicted for sale(Sec.9044,Business
and Professions Cache:9'he Contactor'a 1 utau a Law does net apply or an owner of
property whoballdsor improves thereonand whoducssuch work himselforthrough his
nwnempleyees,providedthat such imptnvementsarc not intended proffered forsale.If, I OCC.GROUT' RES.UNITS
however,the buildingor inlprovermnt is sold within one yearofcompletion the owner-
builder will have the burden of proving that he did not build or improve for purpose of
❑ I,asownerofthePrnpeny,amexclusivelycpmmcting with licensedcomracmrsm QTY. PLUMBING PIil2MI1' ITE _FLOOD ZONE APN
onsuuca the project(Sc,.7044,Business and Professions G 1c:LThe Contractor's PERMIT ISSUANCE
Law does not apply man owner of property who builds or improves thereon,and
whocontracts forsuch projects with a cnntmelor(a)licensed pu munito the Contractor's
License law. ALTER-DRAIN&VENT-WATER(IIA) PEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for Nis reason BACK FLOW PROTECT'.DEVICE OITPTUE P•I:S
SANITARY Y N
Owner Dam _ RECIiIPI'#
TION DECLARATION SC
DRAINS-ELOOR,ROOP,AREA,GOND.
WORKMAN COMPENSAII001.TAX Y
❑ Thereby Orlon@alhavc acmificam of consenuo selGinsure,oracertificme of RECI?FYI'#
FIXTURES-PliftiRMP
Wnrkcrc Compensation lnsuranceoraccnifiW copy themof(Sec.78W,Lab C.)which 1 iF. YN
nvem:dl employee's under this Permit. GAS-EA.SYSTEM-11 .40 ET RECEIP`p#
Policy# ❑UILIIING DIVISION FEES
Company GAS-EA.SYSTEM-OV C ECK FE l
❑ Certified copy is hereby furnished. t
❑ Certified copy is Bled with the city inspecuipn division.
GRP'AS! DIISTLWA T' F,PIOR GEgi
CERTIPICAT1?OF EXEMPTION PROM WORKERS' GREASP.'IRAP SOILS :
COMPENSATION INSURANCE
(This sciammneedtmt be completed Him,penal is for one hundred dollars($100) SEWER-SANITARY-S'I ORM HA.2WIFT, ENERGY PHE
a teal.)
I certifyoan at in pin any
of the work for whichthissubject is issthe tad.lshillkers' WATER fIFA'I'FJ2 W/V1?NTA'?LECTR
not employ any person i mY manna so as m become subject to the Workers' PAID
Cpplicasmion laws of California. Dam WATT?R SYSTEM/TREATING Date ReceiplN
O z Applicant
Z � beatmoCE TO AP.the Work:r.aftCieripco.making this Cm... fol Lienor ie ,you youhouldmost NEW RESIDENTIAL T'LMR. SQ.FT. TOTAL:
1-" > bechwithc ropy the Worker's Compensation provisions I be th.abor CWgyou must
� ; lanhwith comply with such provisions in this pennitshall be deemed revoked. BUILDING FF.E ^#
[� CONSTRUCTION LENDING AGENCY SEISMIC FEE
7-. I hereby urfirm that them is a constriction lending agency for the performance of
V O the wpark for which this Permit i s issued(Sec.304/,Civ,C.) TOTAL: ELECIRIC FEF.
lencler's Name
O U Lcmder's Address - QTY. .MECHANICAL PERMIT PEE PLUMBTNG FEE
1 certify that I have read this application and state that the above information is
eonect. lagrce to comply with all city and county ordinances and stem Powe relating to PERMITISSUANCE MECHANICAL TLE
F-' C/) building construction,and hereby authorize representatives ofthis equormer upon the I -
U 7 above-mentioned pmpeny for inspection purposes. ALTER OR ADD TO MECI I. CONSTRUCTION TAX
(We)agree to save,indemnify and keep harmless the Ca,of Gtpenino against
Iiabilities,judgmems,costs and expenses which may in any waywrneugeinetsaid City AIR HANDLING UNIT(TO IO,OLY)CPM)
in rnmecequenee of egr 'ng of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
tgnamre of Api3l,camlCouncoacm, 2eP5 a1# Fate FAI FAUST HOOD(W/DUCF) PAID
IIA%ARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam Receipt#
Will the upplleam or future building occupart time or handle hazardous melena]
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER I00,01)(0 BTU) L:
Come,Section 25532(a)'t VE.WILATION PAN(SINGLE RESID)
❑Yes Cl No
Will the applicant or(more building occupant use equipment(devices which emit
BOILER-COMP OUT OR I00,01)BTU) ISSUA CEDATE
haeardnus air contaminants as dcfned by the Bay Area Air Quality Management BOILER-COMP OVER 100,000 BTU) p
Dual eU All)
❑Yes ❑No NEW RESIDENTIAI,MECII. SQ.Irl'. JAN
1 have read the Initiation;mammas requirements under Chapter 6.95 of the /
Caffirmin Health&Safety Cale,Sections 25505,25533 an1255W. lunderstundtheI x//433#aY j
if the building Jasnot corrtntly haveamnanb that it is my responsibility to notify the r
.or upaat of the rwluimmenta which must be met prior to issuance of a Cenificros of oil
Occupancy. �h
Owner m nadmnmd agent Date TOTAL: ISSUED BY-
OFFICE