26495 (2) - J APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERI;InNT-FTEM PERMIT NO 26495
APPLICATION/PERMIT L.PLUMBING-MECHANICA
BUILDING DIVISSIOIO NO N BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS .,,y�!� n SANITARY NO. APPLICA9ION SUBM1'TTAL DATE
�I' &4, Uw Ifbe-✓ I` UNIT# LOT
OWNERS NAME: PHONE: CONTRA�NAM / LICK.- N/C CONTROLN
ARCIfITEC/ENGINEER: LI1:3C NO: ADDRESS: /
-� CONTACT: PHONE: ? - BUILDING PERMIT INFO
_ELECTRIC PC IT" r
PERMIT ISSUANCE �JyJ ELECT PL
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL
pyZ Ihereby affirm that l am licensed under provisimisofChapter9(commencing with JOB DESCRIPl[ON
[100 Section 7").f Division 3afine Bminessand Professions Code,and my,license is in PANELS ����[��
FC full force and effect
S r ` � s —
FZRI License Lie. D UP T0200 AMPS
m6h Date Crude, r 201-1000 AMPS
ZO,Z' ARCHITECTS DEQ TI OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O Z— I understand my plans shall the used m public records.
SIGNS ELECTRICAL
Q'-' _1 Licensed Professional
W,m< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. _
0oQ 1 hereby aEirtn that 1 um exempt(Torn the Contractors License Law for the _ rr
3 tr-m following lesson.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE MST.
hIL's 1
which requires a Permit to consumer,cher,improve,demolish,or repair any strunurt POWER DEVICES
}7, prior to its issuance,also requires Nmi
e applicum far such pert to file a signed statement t
yR'] p 0 that he is licensed pursuant to the provisions of the Conlmcmrs License Law(Chapter — rn
a p,oL' 9(commencing with Section 7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC �r y�/ AAiA N
iWMy onM1aheisexempttherefromandthebasisfortheallegedexemPiton.Anyviolationof DATE Ll 20�q
Section 7031.5 hyanyapplicam far.permitsubjecu the.,I canto.civil penalty of OUTLETS-SWITCHES-FIXTURES
nal more than five hundred dollars($500). NEW RESIDENTIAL BLUM _SQ.PI'.
p _
o ❑ I,asnwneroftheproperry,armyanployas withwe6esastheirsolecompenseti0n, STORIES T,Y NSgRUCT10N
y3�a willdo the work,and the structure ismandended muffemd foliate(Sm.0014,Business
and Professions Code:Tim Contractor's License Low does not apply to an owner of
properry whobuildsmimpmveathereomand whodoes such work himselforthrough his
own employees,pravidedthat such impmvnnemaimnotiamndedoroffered outside.If, OCC.GROUP RPS.UNITS
however,the building orimprove(ment is sold within oneyearofcompletion,theowner- T ��
builder will have the burden of proving that he did not build or improve for purpose of
agile')' QTY. PLUMBING PERMIT -r FF.E. FLOODZONE APN
❑ Lu the project
(Seo. rty70F4,Businessng
C licens he Contmorstu License
the project(Sec.oano Busimms and Professions Care)The thenvanand
Llcenumers fasnompplymawithacnfpropenywbosed ds puourat tothe Coreomand PERMIT ISSUANCE T
whence Law.
widte<ommnor(s)licensed pursuanuothe Contracmr's ALTER TA
L.iccnsed.ex IRA) PEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this«sora BACK FLOW PROTECT.DEVICE 001.ID 'LI?S
SANITARY YN
Owner Data RECEIPT#
DRAINS-FLOOR,ROOF, CONU.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
Iherehya(fiml that have ccm.cent ed copynlmul(Ser.38,o,amnificatech FURFURES-PER TRAP �� RECEIVI'#
Workea'Cnmloyce'ionler this oramrtified copy thereof(Ser.38M,Lub CJ which PARK FEE Y N
Pooll"a#Il employers ander this permit /3/oa95—R Y RDC DIVISION
GAS-13A.SYSTEM-1 INC.40VTLETS BUILDING DIVISION FEI?S
Company /�'(� /^r''S GAS-EA.SYS'l EM-OVER 4(RA) PLANCHLCK FEE
❑ Certified copy is hereby fomished.
B`Ce.ified copy is filed with the city inspection division. GREASFpNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEF.
COMPENSATION INSURANCE '
(This section need nor be completed ifthe pennit is forone hundred dollars($100) SEWER-SANITARY-STORM EA.20OFT. ENERGY FEE
m less.)
I certify that in the performance ofthe work for which this permit is issued,l shall WATER HEATER W/VRNTELECR
not employ any person in any mmmm m as to become subject in the Workers' PAID
Compensation Lawsof California. Date WATER SYSTEMITRFATING
z Applicant Date ReceiplM
O
Z O NOTICE PO APPLICAW-.If,afar making this Certificate of Exemption,yon should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
become subject in the Warke/s Compensation provision ofthe Labor Out you must
� , forthwith comply with such provisions or this permit shall he deemed resulted. BUILDING PER Ll�
aQ CONSTRUCTION LENDING AGENCY SEISMIC HE
z I hereby affirm that there is a construction lending agency for the performance of
U O the work for which this permit is issued(Sm.3099,Civ.C.) ELECTRIC FEF.
Leaders Name - `i.i PLUMBING FHB
Q U Lenders Address QTY.tI'. MECHANICAL PERMIT' FEE r.
L) I certify that I have rend this application and state that the above information
acorrect.l agree to comply with all city and county ordinencesnad state laws relating to PERMIT ISSUANCE MECHANICALME
IA buildingconswction.mdhembyauthomerepreaenmtivesofthisciryrommruponthe CONSTRUCI'IONTAX
V 7 oboe-mentioned proprry for inspection purposes. ALTERORADDTOMECH.
^� (We)agree to save.indemnify and keep harmless the City of Cupertino against
Iiubililiu,judgments,cosbandexpenaes which may in any way accrueagainsl said City AIR HANDLING UNIT IT 010,000 CEM)
in consequence of the granting of this permit.
GZ� 6�F�5`f AIR HANDLING UNIT(OVER IO,g10 CIM)
S eof Applmam Cont ch Dete C%HAUS'C HOOD(W/INC'q PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam Receipt#
Will the applicant or future building mention store or handle hamdous material
as defined by the Cupertino Municipal Care,Chapter 9.12,and the tlmhh and Safety HEATING UNIT(OVER 100,00D BTU) TOTAL:
Cale,Section 253J2(ap
11Yes — / VENTILATION PAN(SINGLE RESID) �w
❑ L4N
BOILER-COMP(3HP OR 1(1(1,1100 BTU) ISSUANCE DATE
Will Neapplicum or fmurehuilJingrccupam useeyuipmem nnlevices whichemit � p
A
haramous air contaminants on defined defined by the Bay AAir Quality Management BOILER-COMP(OVER 100,000 BTU) O D
Go neI?
❑Yee NEW RESIDENTIAL MFAH. SQ.FT.
1 have read the hazardous materials requirements under Chapter 13.95 of the JUN - 8 i99
if
uil megaealth&Safety Code.Sections
ent,del it
andsponsi Iundersandthe
if the building does not currently have a tenant,Net it is my responsibility a notify the
cnlpam or the rcyuircmems which most he met prior m iseuancc of n Ccmificme of Cl 1 r Ur GUrCh r
Occu o cy. '
G
uuthorizeJgens O e ISSUED BY:
OFFICE