26006 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPFRTINOB I.Dh ,-PLE�`OCAI. PERMIT NO.
BUILDING DIVISION .APPLICATION/PERMIT PLUMBING-MECHANICAL. 2/N 6/�O FVC/�
BUILDING PROJECT IDF.NN''1'IFICA'I IO
BUILDING ADDRESS: (^7j !!//� SANITARY NO E:
APPLICATION SUBMITTAL DAT
2UO D UNIT# LOT#
DINERS NAliPHONE: CONTRACTOR'SNAME: IJC NO'.
ARC
CT NO
WEEN: LIC NO: ADDRES �� �❑
// S1- Sr
COWACT: ffJJ /pL` PHOO,NE:' BUILDING PERMIT INFO
LECT
- L.O✓{SLit-
-I'(rrI(fL �Lp 290o QTY. B 'RIC PERMIT' _ PEE
B I! PLUMB MECiI
6g ¢ F'I:HMIT ISSUANCE
LICEN$ D CONTRAC'TOR'S DEXLARA'HON APPLIANCES-RESIDENTIAL DISC 110
OCz I hereby affirm that l um licensed underpmvisions of Chapter9(commencing with �_JQ5 s�B(y/I' 011:x5 /�f��
400 Seedim 7")of Division 3 ofthe Business and Professions CM and my license is in PANELS �\��,V\✓ rT�'�
Iullfarco and ell � UP TO 200 AMPS
E¢Fb Licensc Can, 'I//
N 6 d Dae Commu �C.- 201-IOW AMPS
P:^ - SQ.FT.FLOOR AREA S/SQ.ET.
zF0N6
ARCHITECT'esus UIiCLicaccoO (IVIiR 1000 AMPS —'
O Z�❑ 1 understand my plans shall be used as public records. ' 1
C Z-W SIGNS BLECIRICAI. /J�*
J Licensed Professional
Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT'/MISC. ® IY /7 T
LED IF
yU I hereby affirm that 1 at exempt fmm the Contractor's License law for the IY\V/YJ o
W 3IE
la.y following mason.(Section 7031.5,Business and Professions Code:Any city Or county TEMP.METER OR POLE INSI'.
which r quires u perm)to construct,miler,improve,demolish,or repair any structure O f
�NTn
� ,nao its issuance,alsorcqulhen
ins ,plicam forsuch permit It fned lea sigstatement POWER DEVICES DATE
� p0 that he is licensed pursuant to the provisions of the Connector's License Law(Chapter
4 a�' 9(,mono eng with Section 7000)Of Di,kits,3 of the Business and Professions Code) SWI MMING POOL ELECTRIC VALU
Way or that M1cisexempt therefrom and the basis for the ellegedexemptam Anyviblatlon of _y
6
Section 7031.5 by any applicant for a pearl,subjectsthe applicant mu civil penally of GUTLET$-SWITCHES-lIXTURFS a
not more than five hundred dollars(5500). 1
NIiW RESIDENTIAL.ELECfH _SQ.Pf.
111,asownerofthepmprty,ormyemploymswiihwagesasiheirsolecompensotion, STORE, TYPE CONSTRUCTION
y,3_ will Professions
Core: ho ComimuirstLicese Law edanot apply
to an Business
and Prnlcesions Core:Tho Comrucmr'e hlearse Law docs not apply to w owner of ,
property,holmildsorimproves thereon,andwhodoessuchwork himselforthrough his OCC GNOUP RIS.UNITS
Own employees,provided that such improvememsam not inundedoroffenedforsale.If,
however.the building Or improvement is sold within one year ofcompletion,the owner- T T
builder will have the burden of,riving That he did nut build or improve far pw,v,w of
IVC
sale.).
❑ I,nsowner ollhe property,am exclusively commcting with licensed cwhoomrsm QTY. PLUMBING PERMIT. FEE FLOOD ZONE APN
conmmct the project(Soo.7W,Business and Pmfewions Code:)The Comrunor's
License Lawd(cs not applyto onowncroflmopeny,whobuildsorimpmves thereon.and PERMITISSUANCE
whocnuawts for such projects with acomractm(s)licensed pursuant to she Contractor's ALTER (EA) PEE SUM
License MARY
Law. -
❑ I mn exempt under Sec. ,B&P C for this mason
BACK FLOW PROTECT.UIiVICE S
SIDE E:
SANITARY Y N
Owner - 1) O RECEIVE 11
DRAINS-FLOOR.ROOF.AREA,COND.
WORKMANCOMPENSATIONDECLARATION SC11001.'I'AX Y N
❑ ers Co affirm lonllhrance ora certified
themcf(insure,ore.I,C.) hioh FIXTURES-PER'IRAP RECEIPT#
Y. Wnrkcrs'Compcnsminn lnsurenccoracertifndcopy lhuwf(Se,x 3800,Ltb CJ which - PARK NI?E YN
RECEIPT'#
lr coversmllemp ;pdcrlllijaTf�i1. GAS-FA.SYSTI:M-I INCA OUTLIiTS BUILDING DIVISION PI3B5
Policy a 7 77(L JJ���F
Company r ashed. GAS-EA.SYS'TEM-OVER4(EA) PLANCIIIiCK FEE
❑ Certified copy is herchy ftimished. �e
❑ Certified copy is filed with the city mspeshon division. GRFASE/INDUSIRL WASTE INTERCEPTOR GRADING FEE "
CERTIFICATE OP EXEMPTION PROM WORKERS' GREASETRAP SOILS FHE
COMPENSATION INSURANCE
(This section need not be completed lithe Ismail is forone hundred dollars 15 lW) SEWER-SANITARY-STORM EA.20l ENERGY FEE
orlessJ
I ttnifytha inthe performance of the work forwhich this permit is issuW,l shall WATER HEATER W/VENT/HLEC1"R
not employ any person in any m as to become subject to the WOrken' PAID
z Cma,madmi Lnws of C.Ifi mie.manner
so WATER SYSTEMTREATING Dam Receipt#
Applicant
z 0 NOTICE TO APPLICANT:If,after making this Cartlficam of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
r�+ LGI becamosnn
ubjecthe Workers Conapemnlion provisions ofthc Labor Code,you must #
7 forthwith comply with such provision .,,hiss.,,his pnmit shall he ed
deemed revok . BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby uffima that then is a construction lending agency for the performance of
the work for which this permit is issued($$epp.JW),Civ.C.) TOTAL: ELECTRIC FEE
LU4 Lenders Name CYLFL�V� T- PLUMBING PBI?
F Lender's Address - Q-PY. MECHANICALPERMI'T PLP
V 1 certify that I have tad this application and slate that the above information is MECHANICAL.FEE
�" LU correct,l agree to comply with all city and county ordinances and stale laws relating to PERMIT ISSUANCE
C,Gbuilding construction,and hereby nommize representatives ofthis city mcnmr ups the
V z above-memioned property for inspection facipmes. ALTER OR ADD TO MECH. 'CONST'RULTION'I'AX
(We).,mem save,indemnify and keep h:umlese the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way acemoti,ainsl said City AIR HANDLING UNIT CTO 10,01X1 CFM)
in come,cence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,11(1(1 CFM)
Signmurc of ApplicanVCamranor Date IiXHAUST I IOOD(W/DUC) PAID
IIA%ARDOUSMATI:RIAI.SDISCLOSITRE 1 IEATINGUNIT(TO I AMOBTU) Dam ReceipN
Will the applicant or future building occdpentstore Or handle hmzurdous materialgPATING UNIT(OVER 100,000 B'IV7 'TOTAL:
as defined by the Cupertino Municipal CWe.Chapter 9.12,end the Health and Safety
Cale,Section 2!5532mEyes N VENTILATION PAN(SINGLE RI?SID)
ISSUANCE DATE
Will thou licarnor future buildin tusec. mrdeAceswhich emir BOILER-COME UHP OR 100,000 BTU)
pp goecupan q Imes
haou dam air examominmts es defined by the Bay Area Air Quality Management BOILER-COMP(OVFR I 00,000 BTU)
❑Yes cyst No NEW RESIDENTIAL MECII. SQ.FT.
I have read the hessfdous materials requirements under Chapicr 6.95 of the - r !( '
-- California Health&Safer Cade,Sections 25505,25533 and 25534. lunderstandthat M
if thehuild(themsn".. ply by t int,elphat fictuardyirespunsihilitymificar the JA .,
nccupanl (therequircm I t' 1 be et prior to issuance of t Cmificate of a(71Af
y -
0 '9 a y�.�
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ama_h�oo'u4 ege/1 - Dae � TOTAL: ISSULfOI a
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