26861 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER'1'INO PERMITND.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIF'ICAT'ION 26861
BUILDINGADDRI55: SANITARY NO. APPLICATIONSUBMHTALDATE
�-+ ✓v LOTa
O ' ' SN M _ as
t;HpNF,: COM' CTOR'S NAME LIC NO: NIC CONTR(Ol.a�
RCt11TFC1" INFER: LIC NO: ADDRESS: ❑
coNACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
L E PB M
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION pJPUANCES-RESIDENTIAL
p0Z I i erchy 70od)altitmthatl am licensand usinss nprovisions rfeionsChapter Code
ad(commencing se with
FJ 00 SCniorce and ofllivision Sof the Business end Professions Coda,end my licemeis in pprypy$
full r cCand-'feet.
FTW license Clacx I,,,#_ UP T0200 AMPS
of Date Comment, 201.1000 AMEX
>0yZ ARCIiITECTS DECLARATION OVER It100AMPS SQ.FT.FLOOR AREA $?SQ.FT.
OZ-0 I understand my plain shall be used as public records.
P r/+f w SIGNS ELECTRICAL
2 F,j Licensed Professional
pzd'¢ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XOyu I hereby affirm that I am exempt from the Contraaora License law for the
n13am fallowing reason.(Section]031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
F'1i--Oa which requires a permit to construct,alter,ire my
,Wr 7 to its issuanee,id. thea licant for such Permit
shmaimmectum POWER DEVICES
K� 0 Prior requires pp pcmdtta fileaxi,La natemem
W z n O that he is liters-pursuant ro the Provisions of the Ce Business
and Pae law(Chapter
6,6ofi' 9(commencing with Senium]t%Npof Divisionlof the Businua utd ProPossions Code) SWIMMING POOL ELECTRIC V�ALU�ATIO=a
W_H othat hels Ly by any
and the Permitsubjfor eascgedeaemption.Any violation of UTLETS-SWITCHES-
F Z Q Section ID3 n by any applicant far a permit subjects Ne applicant to a civil lonely of FIXTURES
�=- i are than Eve hundred dollars($50%
CFo sewnernHhepropeny,orm to eeswiNwe esastheifsolecom NEW RESIDENTIALELECIR _SQ.pr.
yemp Y B pcnsetion. STORIES 'TYPE CONSTRUCTION
y3=°
is do the work,wJthe struaurc is not intended oroffcred forsale(Scc.](H4,Business
d professions Code:The Contractor's License Law does not apply to an owner of
Property whobuddior improves do eam,and who docs such work himsclfor through his
uou employees,provided that such improvements are notintended mothered forsale.It, OCC.GROUP EIIN
ITS
however,the building or improvement is sold within one yearofcompletion,rho mmer-
huilder will have the burden of proving that he did not build or improve for purpose of
1-1
❑ Las the project
70s emexdusis an contracting with ' sed cr,ntrectorsro QTY. PLUMBING PERMIT FEE FLOOD ZONE,
onswa the project(Sec.]t144,Business and profession ode0 a Commemr'a
License lawdoes not apply maaownerofpropenyw dsorimprove ninon,and PERMIT ISSUANCE
whocontracts forsuch projects wiNacontracm ce _ammuannotne o-acmr's
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I em exempt under Scc ,B&P C for this BACK FLOW PROTECT.DEVICE, OUTS—IDE FEF_
SANITARY Y__N
Owner Dam DRAINS-FLOOR,ROOF,AREA,COND. RFCEIPTN
WORKMAN MPENSA ON RATION SCHOOL TAX Y_N
❑ Ihen,by affirm thetl B eacenificamr, Gimute,/°� roof FIXTURES-PER TRAP RECIi1PTp
worker:Cimmerian! mnceoracceif thereof(Sec.36pW b twhich PARK FEE y N
vers
ell cmpinya'su er Ni. noir. _` GAS-EA.SYSTEM-I INC.4 OUTLETS RF.CEIPTp
Policy,
ol cy M BUILDING DIVISION FF.BS
Company GAS-EA.SYSTEM-OVER 4(EA)
❑ Ccnilicd cop is hcrcbyf ` PLANCHECK PEE
❑ CCrtifted cop is fled wird N i insists smr. GREASFANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTI ATE OFE F. PTION FROM WORKERS' GREASE TRAP SOILS FEF.
MPENS IONINSURANCE
(T'hi,s,ceionneednot omplebal ifthe pernit is for one huhdred tars($100) SEWER-SANITARY-STORM F,A.2WP1'.
or less.) ENERGY FEE
Icenifythointheperfornanc ftheworkforwhichthis nisiourallsball WATER HEATER WNENT/ELECR
not employ any person to my mann so as m become ject to the Worked PAID
Comperationlawsof California. Date WATER SYSTEM/IREATING
Q Z Applicant Date Rcaciga
Z NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT.
Fy become subject to the Workch Compensation provisions of the labor Code,you must TOTAL:
0 forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
l�
y D CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that Nen,is a construction lending agency for the performance of
U O the work for which this permit is issued(Sm.3097,Civ.C.) ` ELECTRIC FEE .QI
Lender's Name
00 U Lcoke,Address QTY. MECHANICAL PERMIT FEE PLUMBING PEE L
LLI 1 verify Nread th
that 1 have is application and slam Nat Nmove ove infamu
tndrn
F correctlagree mcomply with all city and county ordinances and slam lawarelating1. PERMIT ISSUANCEMECHANICAL FEE xa�
(n building conafuction,and hereby indamixe repmsenmfivesofhi,vhym on enter upthe '
U Z uMwcmefuloned property,for inspection purposes. ALTER OR ADD TO MECIL CONSTRUCTION TAX
(We)agree us save,indemnify and keep harmless the City of Cupertino against
findoldics,jmdgmen ,cnn,andnape ,which ayumnywayaecru ,mostsaiJCay AIR HANDLING UNIT(T'010,00h CFM)
nac4lpour t -gro noir
ss in
A0 , AIR HANDLING UNIT(OVER IO,Uf10 CFM)
ig mu pylic' Con mctof Date EXHAUST HOOD(W/DUCq
PAID
IIAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,tgO BTU) Dam Receipt M
Will the applicant or future building ovcapon store or handle harerdous material
is defined by the Calendar,Municipal Code.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOT
Code.Sermon 25532(x)?
11 Y. 0 N VENTILATION FAN(SINGLE RFSID) 2
Will the licard or future buildinoccuant us< BOILER-COMP(3HP OR H*,(IOU BTU ISSUANCE GAT&V
WP 8 P equipmir Quality Mar i,mr,rd ) 7 try y syr L
Dismeoux air mnmminantx¢c defined by the Bay Area Air Quality Management BOILER t COMP OVER LW,0008TU) AUG 121994
is c^ ❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
1 have read the hatool us materials on uiremetns under Chapter 6.95 of the
California Health&Safely Code,Sections 25505,25533 and 25534. 1 understand that
L,
tM1c bullJing Ines not cumcndy huvCamnant.that it i.e my resgmsibility to nmify the GII r vI- wrenl BvU
wcmpunt of Ne rc'muctnentn which man be met prior to isuance u fa Cc dhoom of
(katp:ntcy.
OwncroruuNonmdagefn Dam I 1 '1 L: ili� ISSUED BY: I
OFFICE