26004 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINOBITLDING?LI I-1GFERMI"f NO. 26004 BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL O O O�//��
f
BUILDING PROJECT HAIN'FIFICATION 2
LLDrIINNG ADDRESS six SANITARY NO, APPLICATION SUBMITTAL DATE
Cr S UNH'M 1-01'0 [,e Ijrq
1Yi PIIDNI3: C EMl(YfAn�ID _� IEilf� l N/C CONTIIROLq
ARCHITECT/ENOIIINNHEERR:•Y IJCNO:. DRESS: Yii✓^JI(\/�./'J7/1 -�/,�y - ❑
CONTACT PHONE: �/ '�4I BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT PER
BLDG F:LIiCI' PLUMB MECII
PERMIT ISSUANCE El ❑
LICENSED CONTRACT'OR'S DECLARATIONAPPLIANCES-RESIDENTIAL JOB DESCRIP'T'ION
ny.Z I herebyafirm that l amlicensed underprovismas of@apter9(commencing with ,
F100 full to.addof Division Sof me Dusinesv and Prof vi C ny license is in PANELS y
F2{{'' full force end cRat. /�/ jr••jJ�/���,V��-
W � se ' `•O Lic. �� � IIP T02W AMPS
mora Da INTS or 201-TWO AMPS
Fye ARCI IITFC'FS DE SQ.FT.FLOOR AREA S/SQ.F1'.
ZO_m p—p I understand my plans shall be used as public ords. OVER 1000 AMT'S ..
SIGNS ELECTRICAL B
bN Licensed Pnfcasiono] INALED
IY OWNER-BUILDER DECLARATION SPECIAL GIRGGIT/MI$G. ® ry
K O y I hereby affirm, I nm exempt from the Commodes License law for the \{{{���/a+
�LLOm follnwmiloatson.(Section]031.5,Business and Professions Code.Any city or county TEMP.METER OR POLE INST.
which requires a permit to construct,alter.Improve,demolish,or repair any swcmle j
iiIIn} pai.moilsiawance.0sorcyuimslheupplicamfnrwchpermilmfleasignedstmemem POWER DEVICES DATE �V
WyorO p that he is licensed pursuant to the provisions of the Contractors License Law(Chapter
mx0� 9(comntencdng with Section 700B of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION r
ud or that he is exempt herefrom and the basis for the alleged exemption.Any violation of
FZQ
Section 7031.5 by any opplimin for n permit subjects the npdiesnd to.civil penahy of OUTLETS-SWITCHES-TEXTURES
aot more than five hundred claims($500),
K m ElI,esowneroftbepropeny,ormyemployeeswiihwagesastheirsoleco,nNnsvmimq NEW RESIDENTIAL ELECRt _SQ.FT. STORIES TYPE CONSTRUCT ION
wit l do the work,and the strucmm is not intended or offered for sale(Sm.7(44,Business
and Prelfiessions Cede:The Convector's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himselfor moral his OCC.GROUP RES.UNITS
.on employma,pmvided lhnatich improvemenlsafenot imerabsimOffered hassle.If,
however,the building or improvement is sold within one yearormmpletion,the owner. 'f0
builder will have the burden of proving that he did not build in improve for purpose of
sale).
❑ I,asownerofthepropeny.amexclunivelyconvactingwithllcenudconnamorsm QI Y. PLUMBING PERMIT PEE II,000 ZONE - APN
construct the project(Sec.](144,Business and Professions Cede:)]Tie Contractors
License Lawdoes not apply to an owneaofpropeny who builds or impmveslhcreon,and PERMIT ISSUANCE
who cmuraas for such projects with ucontmcmr(s)IicensW pursuant Io the Contrvc(ora
License law. ALTER-DRAIN&VENT-WATER(HA) FEE SUMMARY
❑ 1 am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSI E :FS
SANITARY Y—N
—
Owner - Date RECEIPT'#
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMANCOMPfiNSAT10NDECLARATION SC11001.TAX V N
❑ ElicrubyaffirintherfComfenotimInsuance oraidmeof cnnsnnmself-insure,ar ecenlfi which�uteof 1; RECF.IfTp
FDC[ORES-PIiR TRAP
Woken Cmployees order
ifed copy thamf(Su.38W,Lnb CJ whirl PARK IEiE Y N
uwen all employees under tale tECISION
Y Penni. GAS INC.INC40UI,1?'1'S BUILDING DIVISION PEES
Policy p
Company GAS-EA.SYSTEM-OV BR 4(EA) PLANCI IECK IEE
❑ Certified copy is hereby famished.
❑ Certified copy is fled with the city inspection Jivieinrt GREASMNDUSTRL WASTE INTERCEPTOR GRADING PEE
CERTIFICATE OF EXEMPT ION FROM WORKERSGREASE'I RAP. SOILS FEE.
COMPENSATION INSURANCE ,
('ITls section nein not la,completed ifthc permit is for one hundreddollars(SIW) SEWER-SANITARY-STORM EA.200FI. EN17RGY FEE
or IcsIe
I celoy that arson in any ancer so as for whichthobjectlo issued loallkers' WATI3R IIIATHR W/VP.M'/ELECf0.
not employ any person in any . Date so as m hecmnc object to the Workers' PAID
Compensation Wws of Celifomia. Dam WAE'IiR SVSTfiM/fR1iATING Date Receiptp
Q z Applicant
,Z � NOTICE TO APPLICANT:If.after making lits Ceniflcme of Exemption,you should NEW RESI DENTIAL PLMR. SQ.IT. IOTA(-;
p+ I, object become objeco the Workers Compensation provisions of the Labor Cole,you must -
Fa 7 forthwith comply with such provisions in this permit sbull b,decided revoked. BUILDING FRT..
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herehy off rat that there is a em smardon lending agency for the performance of
V 0 pati
Ile work foraddelthis tis isauN(Sec.3o9],Cty.C.) 'TOTAL: ELECTRIC FEE
Lender's Nae
0 mF Leader's Address Q-I'Y. MECHANICALPERMIT FETE PLUMBING ItE
U 1 cenily that 1 have rand(his application and state that the above information is MECHANICAL FEE
W correct.l agree m comply with all city and county ordinances and state laws dining it) PERMIT ISSUANCIi
Uj bvtldmitemmructim,ind hereby ambortre epresen es of this city m cmerupon the CONSTRUCTION TAX
V z bo cal pmpeny for ins tion pu ALTI3R UR ADD TO MECII.
(We)ngrec ,toil ify amt Jess t City of Cupenin,agu ml
liabili(ia,jud casts xpense n y w.y.ccrueegains said Cit AIR HANDLING UNIT('TO 10}IW CFM)
onseyu c the gr i of th'
AIR HANDLING UNIT(OVER 10,0110 CPM)
Signs roof Applican mmcm Dam EXHAUST HOOD(WNUCT) PAID
mA BOGUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt N
Will the applicant orfumre building occupant store arloame tomartmus material HEATING UNI'f(OVER 100,(Xm RTU) 'AL:
us defined by the Cupertino Municipal Code,Chapmr 9.12,anJ the Hea11M1 and Safety
Cade,Section 25532(44 VENTILATION FAN(SINGLE REBID)
❑Yes ❑No
ISSUANCE DATE
Will theapplawat
conterminous
as building by
Buy Are.
Manageemit BOILER-COMP(3HP OR IIXI,g10 BTU) r AI
• District? air comaminanta as defined,by the Bay Arca Air Quality Management BOILER-COMP(OVER 100,000 BIG)
'�7r
t
District? 'I
❑Yes ❑No NEW RESIDENTIAL MIiCH, SQ.Fi'. JAN
fl pr' 11 lyyb
1 have read the hmni
.n im,materials haremems under Chapter 6.95 of the JI'1`V
Culifomidllcal(h&Safety Cade,Sections25505,25533md25534. [understandthat 1tUL Tt,��\
ifthe building does not currently have a tenant,that it is my-respomibility to notify the Cily Uf `yl L�111'1V
cupunt of the rcyulremema which must be mm prior la isnuunc<nf a CeniOeme of ^_- -"
Occupancy. "
Owner-roil nihod agent Data TO]AL: ISSUED BY:
OFFICE