26919 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BVFCDINC-ol"hu I RIC AI. PERIOD NO.
APPLICATION/PERMIT PLumnlNr,.mlxcunrvlcnh n C A
BUILDING DIVISION BUIIAIN''GPROJECTIDFIV'1'IF'ICA'r10N Lv �7
BUILDING AR,'S: 9 NITg a I SANITARYNO, APPLICATION SUBMITTAL DATE.
OWNERS NAMP. PHONE. FRACTORS NAME: - LICN
�� N/C CONTROL p
r' RCIII'I TiCT/IiNGINEIiR: LIC NO: ) S: ❑
:ONTACT: PHONE:
QTY. ELF,CFR[C PERMIT FEE BUILDING PERMIT INFO
BLDG •CECT It CIT
PERMIT ISSUANCE oit—
LICENSEDCONTRA OR'SDECLARATI N APPLIANCES-RESIDENTIAL TOB DES DESCRIPTION
p tyZ I herchyuffinn that em licensed Serpmvisions of Chapmr9(commencing with
00 Section]000)uf Division Sof thea and Professions Code,and my licersu is in pgNELs
full force and-(teat. c
QZZy) fall to Class Lic.p UP T0200 AMPS JI,^SVl
oFxs 6 y Date Ciarmen r 201-1000 AMPS
Z Ovz ARCUITECPS DECLARATION SQ.IT.FLOOR AR2A E/Sp.FT.
OZ-0 I understood my plans shall be used n public records. OVER I WO AMPS �Qla�
SIGNS ELECTRICAL LJ 11.101
Licensed Professional
PSS KK Ot I on,eUILDERDECLARATION. SPECIAL CIRCUIT/MISC.
�OyF Ingherebynese n.(Se that 1 on,exempt from the Casions Co License Law for the
sD ii, whichingreamn(Seni I.consumer,
and Profession Code:Any city of county TEMP.METER OR POLE INST.
E] which its iss s n permit re conswd nlmq improve,demolish,or repair any swcmre
;!j< prions itsissuance,
purhnreyufivetheapPIvisiins for such permits License
Lo statement POWER DEVICES
tL OC thatheisurnifwpursmtioto theprovisionsofthe he Bmimrs License Low(Chapter
L{x,e4 9(cotmnencing with Section]O(111)of Division3 of he Business end Professions Code) SWIMMING POOL ELECTRIC VALUATION
X�_y or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETSSWITCUES FIXTURES ^� r]^ 1` r,
F• Q Section 1031.5 by any applicant for a permit subjects Nenur - -
e appli.t to a civil poorly of J_ `�\ [
not more than Eve hundred dollars(8500). 4
qo ❑ I,esownerofthepmpeny,mmyempinyen withwegesasthcirsal¢compensation, NEW RESIDLNTIAh BLCCTR _SQ.FT.. STORIES 'IYPECONS'TRUC'HON
y322 willdo the work,and the swaroeis not intended unaffected formic(Sac.]044,Business
and Professions Code:The Contractors License Law does not apply to an owner of f
pmperty whnbuildsorimpmves thereon,unJ wh�Joessuch work himselfor throogh hie OCC.GROUT' RES.UNI'T'S
own emDloyeca,provided thauuch improvemenu ere not imm�dcd oroffcned Tar sale.If,
however,the holding or improvement is sold within one year ofcompletion,theowner- s.
builder will have the burden of proving that he did not build or improve for purpose of
sure.).
❑ 1,us owncrofthe property,am exclusively contracting with licensed contractors to QTY, PLUMBING PERMIT FEB FLOOD ZONE APN
commuct fie project(Sac.7044,Business and Profusions CcdcO'Da Contractor's
License Law docs not applyto anownerofpropeny who builds or improves thereon,and PERMIT ISSUANCE
who contracts for such projects with aumtractorim licensed pursuant to the Conwmnrr )
License Law ALTER-DRAIN&VENT-WA A RIF SUMMARY
❑ I am exempt underlies..,B&PC for this ramon OUTSIDE,FEES
BACK FLOW PROTECT,GIVE
SANITARY Y N
Owner DateRECEIPT h
DRAINS-Iq.00N,ROOF, r NU
WORKMAN COMPENSATIONDECLARATION SCI100L TA% Y N
❑ era Ceypmeariar Ins. ccoracc:neof ron thent ef(S=rre,a.LcbCfe scofhick RIiCLIPI'
PIX'1'GREg�PER TRAP
Wmrs allemloyeesnlnsumttrmit, find atpythereof(Sec.JB00,LobCJwM1ich PARK PEE Y N
overs ullempinyeeauWer Nis pcmtit GAS-EA.SYSTEM-]INC. UT • S RP.EI 'x
Policy p BUMGKIYAJON FEES
Company GAS-EA.SYSTEM-OVER 4IFAPLANCHECKF'-
❑ Certified copy is hereby famished.
❑ Candied copy is filed with the city inspection division. GREASEANDUSTRI.WASTE 1NTERCEPI'. GRADING III. ia—aa
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS i �.
COMPENSATION INSURANCE
(This section need not Ie completed if Ne Permit is for one hundred dollars(SIM) SEWER-SANITARY-STORM EA,2MM. ENERGY P,
or hold _a
I certify that in the fraficmmon of the work for which this permit is issued,Estill WATER HEATER W/VENTIELECTR
not employ any person in any manner so as to become subject to the Workers PAID
Compensation Lawsof CWifomia. Dole WATER SYSTEMTREATING Dam Reiptp /
O z Applicant
z 0 NOTICE TO APPLICANT:If,after making this Ceniftcam of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
.In become subject to the Workers Compensation provisions of the Labor Cede,you must
a > farthwlth comply withsuch Frackinnsor this pcmtit shall be deamed revoked. BUILDING FIE
a (] s CONMUCDON LENDING AGENCY SEISMIC FSE 2 `d)
= z I hereby affirm that there is a construction lending agency for the performance of
V O the work for which this .it is issued(Sar.3097.Civ.C.) \ ELECTRIC FEB 14
\
4ks Lender's Name Lh
a s PLUMBING TLE
Lenners Address Q'I'V. MECHANICAL PERMIT FRE
V 1 certify that 1 have read this city
unroion ayit,sum that an state
iws miming is w
correct. lagrec to comply with ell city enA county ordinances and state lawn relating to PERMITISSUANCE MECIIANICAI.FEE
building emawa rim,rid harchy molam vn representatives of this city memo upon the CONSTRUCTION TAX
UZ above-mentioned
V z property for inspection proposes. ALTER OR ADD TO MECI I.
(We)agree to save,indemnify and keep harmless the City of Cupcnino against
liabilities,judgments,casts and expenses which may in any way acrue against said Ciry AIR HANDLING UNIT(TO 10.000 ChM)
in cn -1f 11nyami,of this permit.
AIR HANDLING UNIT(OVER IO,IXq CPM)
S'llmorat,o pplicant/Comm Data E%HAUSTHOOD(W/DUCT) PAID
1
HAZARDOUS MATFRIAIS DISCLOSURE HEATING UNIT('1'O 100,000 BTU) Uste Receipt N
Wiltdo.aplicant or future building occupant Wore or handle harsrdous material HEATING UNIT(OVER 100,p(p BTID TOTAL:
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(n)1
0Yes ❑No VENIN'ILAI'[ON PAN(SINGLE RESIDE
BOILER-COMP(31 IP OR 100,000 B'TU) ISSUANCE DATE
liftWill the ucommatrus.building by henmx equipment usury Mainfhemit p p P9.
Wool?t air camaminants n define¢by the Bay Arm Air Quality Managemem BOILER-COMP(OVER 100,000 BTU) r W lJ
istrid'1
❑Year ❑No NEW RF.SIDENTIALMECII. SQ.FT. 1995
I have rend the'Islanders mmeriuls requirements under Chapter 6.95 of the S
Califi:mie 11eWth&Safety GWe.Sections 25505,25533 cod 25534.1 undcmund that f�•
ifthe building does not currently have a tenant that it is my responsibility m notify the CITY Ur lfUYthlK
occupant of the requirements which most Is,met prior to issuance of o Cenifirme of
Oce.forey. is
Owner.,amborieed.,or Date kwr\ ISSUED BY:
OFFICE