26658 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUILDING-ELEC'TR'I'CAIPERMITNO.CITY OF CUPERTINO PLUM ING MECHAN
TCAL
BUILDING DIVISION APPLICATION/PERMIT IUIIAID:PRODECIUEN1EFICATItN
26658 vvJO
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
JUPS NAME:
PHONE: CONT'RACTOR'S NAME: 1 I,IC NO:
g N , N/C CON'IROLM
� ARCtI1TCCIpiNGiN :R: LIC NO: ADI RES L ❑
1 �1u e wooD !?d. -54avc.
CONTACT PHONE: a BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEF,
BLDG ELECT PLUM,4 MICA
PERML ISSUANCE 0 4 ❑
LICENSED CONTRACTOR'S DECLARA'DON APPLIANCES-RESIDENTIAL
Metz I hendwaffirm that l um licensed underprovixiuns mf Chapter9(Commencing with JOB DI?SCRII'l'ION
0O Section700f.f Division 3 ofthe Business and Professions Code,and my license is in PANELS / I
FCZ,ufull forty on Ic e'L
LicenI.IL.k 2 75 UI"T020f1AMPS - '" COT W.
F=. Data Conln¢mr 401-IOfm AMPS
z O,z ARCHITECTS D17CLARATION OVER ILYIO AMPS - SQ.IT.FLOOR AREA $/SQ.IT.
C z—M I undersmnd my plans shall be used as public records.
SIGNS ELECTRICAL
a y g j Licensed Pmfesslonal
�a�a OWNER-BUILDER DECLARATION - SPECIAL CIRCUIT/MISC.
XOaF I hereby affirm that 1 am exempt from the Contractor's License Law for the
6136.m fullewin,mawn.(Se,lian 7031.5,Rmonessand Professions Code:Any city ter county TEMP.METER OR POLE INST.
which requires a permit to construct,star,improve,demolish,or repair any structure -
CQ7 "i-lo its issuunec,als nanires thaii'licaut for such permit to file a signed statement POWER DEVICES r
pT_
no that he is licensed panuunt m the provisions of the Contmaors License Law(Chapter
1 pa' 9 o tononncing with Semina 7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
6_o, orthi is exempt forefront said the basis for the alleged exemption.Any violation of OUTLITS-SWITCHI6-WX'1'URES -JK
Se�Q Section 9031.5 by anyappliennl En a permit nobjena the applicant to a civil pariah,of .�
N not more than rive hundred dollars($500). NEW RFSIDENTIALELF.CTR —SQ.FT.
p ❑ 1,asownernf tepmPedy.mmyemployces with wugesastheirselecompensminn, is STORIES TYPECONSTRUCTION
a3— will do the work.andthe structure isnot inrandedorofferedfor sale(See.10ll,Business � fl
and Professions Code:'I'he Cmdownts License Law does oat apply to an owner of s
pmpcny who buildsorimpowesthemmaned whodeas such workhimself rrthroughhis
employees.providNm
tatsucliimproveentsarenatinmendedmrufl'erest forsale.If,
however,the building or improvement is sold within one year ofcompletion,mcownar- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of at
a de.).
❑ I.as ownerafthe Property,amexclusively contracting wit Iceland mm
sed coctors to QTY. PLUMBING PERMIT' U z0bw
A�
rammer the project(Sec.11144,Business and Professions Code)The Co
mmctors
License LawdowintaMlym an ownerof Progeny who builds or improves thereogand PERMIT ISSUANCE'
whoumnaetsforxuch projects withacuntinetor(s)licensed pumuum mthe Contractors
License Law. ALTER-DRAIN&VEND-WATER(IA) FEE SUMMARY
❑ I nm exempt under Site ,B&P C for this rennin BACK FLOW PROTECT.DEVICE. OUTSIDE HE
SANITARY - Y N
Inner Dale DRAINS MR, RF.CIIIFT#
WORKM1TAN COMPENSATION DECLARATION SCHOOL TAX Y N
liftIhertby affim that1hoveacenifcam ofemsormuo self-insure,or a certificate of R CFIPTN
FIXTURES-PFR TRAP
WnrkerrvCmnpensainn Insurance ora certified copy thereof(Sec.3g00,Lab CJ which PARK FEL' YN
coven ullamly�y ppc�ratM1is permit. GAS-EA.SYSTEM-1 INC.4OUTLI!TS RECIi1PI'M
.PulicyN JLYtl—YW _ BUILDING DIVISION FEES
Company - R" GAS
GAS-EA.SYSTEM-OVER 4(H/H PLANCHECK FEE -
❑f third copy is anarchy banished.
�rCenified copy is Bled wine city inspection division. GREASMNDUSTRL WASTE INTERCEPTOR GRADING HE
CERTIFICATE OF EXEMMON MOM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCH
(TTissectior need not be completed ifthe permit is form hundred dollars P$100) SEWER-SANITARY-STORM FA.20r ENERGY FEE
or less.)
I certify that in the perfwmanceof the work for which this permit is honest.)shall WATER IfFIE.R W/VENT/ELECR
not employ any person in any m as to become subject,,the Writers PAID
z Compensation Lawaof Califnmia. Dale so - WATERSYSTRNUTREATING
Data ReceiPlp
Applice l
7, NOTICETO APPLICANT:If,after making this Ceni fiesta of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
F' 0 become suhje l to the Workers Competitor.provisions of the labor Code,you most
a 5 fonhw It a wmnply with such prow simw or this permit said l he deemed revoked. BUILDING FEE
1 Q CONSTRUCTION LENDING AGENCY SEISMIC FIiE
Vz I hereby affirm that them is a cunsrtperformance uction lending agency far o perfoance of TOTAL: ELECTRIC FEE
Or the work for which this permit is issued(Sax.3097,Civ.CJ
Li. r, Lender's Name a I'IAMBING FF:F. /�.7�
i.cnders Address QT'Y, MECHANICAL PERMIT FFG UV
U 1 ready that I have read this application and state that the above information is
Fr-m 4 correct.Iamachicomplywithallcityandeuunry oNinmees and state laws mletingm 1'FAMITISSUANCL' MECHANICAL ItE
hulldiagconsnuction.and hereby.authnrize representatives dmis city ministration the CONSTRUCTION TAX
U 7 abase-memianed property for inspection purposes. ALTERORADDTOMECH.
(We)agree transit.indcmni fy and keep harmless the City of Cupertino against
habilities,judgments,costs andexpenses which may in any wayacerueugainst said Cty AIR HANDLING UNIT(TO 10,000CFM)
Arco ail thegmnting is Pc
AIR HANDLING UNIT(OVER 10,00 CFM)
Slgnmureof Applies /Con..mor Data EXHAUST HOOD(W/DUC) -
PAID
AZARDOUS MATERIALS DISCLOSURE 1 IEA'IING UNIT(TO 100.000 BTU) Data Receiplp
Will to applicant cincture building occupant store or handle haeardous material I IFA'1'ING UNIT'(OVER 100,1X10 B'I'U) TOTAL:
as defrost by the Cupertinn Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)9
❑Yee El Na NTIVELATION PAN(SING(SINGLERESOD)
ISSUANCE DA'1'li
Wilhhen licumorfunnehuildm tusec tnrdeviceswhicltemir BOILER-COMP(JHPOR Ifp.gXI BTU)
�heza mous air contaminants as defined by to Bay Area Air Quality Management
UisVin!' BOILFR-COMP(OVER 100.OW BTU) Y W I N'
❑Yes 13 No NEW RESIDFNDAi.MIiCN. SQ.FI'.
I have read the hazardous mmmials acmucmm
es under Chapter 6.95 of to AUG 10 �g94
E
.I iw th&SafetyCode,Sections25505,25533and25534. Iundertandthatding dons not currently have a tenant,that it is my responsibility tonotify to
of the requirements which must be,met prior to issuance of a Ceificate ofCI I Y ur k•tert II"cy.r uutoriecd agent Data TOTAL: ISSUED BY:
OFFICE