26714 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINOB ILDING."TuTRICAL PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. 26714
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BUILDING DIVISION BUILDING PROJECT IDDNTIFICA'I ION L 11 4
BUILDING ADDR�/ESSS: �7 //�� \\ /n/lk///�)1 I ^^��CC 1�.I ''T'' SANITARY NO. APPLICA'JION
SSUUBMI'ITALUATF.
E/L 1/�j�1��A"IC J :S a'- 1l 41 .�aaAITI v/ ' LOTM
WNF.RS NAM Ii: CONT R'S & LI 0: NIC CONTROL 0 C OT1Ll� �� - /��
•ARCHIT1707ONGINEER: LIC NO: AD RESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB F.
PERMIT ISSUANCE El El CONTRACTOR'S DECLARATIONAPPLIANCES-RESIDENTIAL. JOB DIISCRIPI'ION
y�Z lherebyaffirm Nut l am licensed under provid"wefclux"T'9(commencing with
00 Secured M)of Division 3 of the Business and Professions Code,and my license is in PANELS
ty VE milm.radefreC26 27403 UP T0200 AMPS
Fztu Liven u�Iy —slC... - ll�ll Lic,p
y 6 v6i Date�(�(,(.�chat 201-111(10 AMPS
z 05:,2 rr• {{--) AARCI II'rECTS DF.CLA ATIO OVER IWO AMPS SQ,FT.FLOOR AREA $RQ.IT.
O z'— I undersand my plans shall be used as public records.
SIGNS ELFiCI'RICAL
Licemed Professional
OW Win exam DER d the CoATmN SPECIAL"CIRNIT/MISC.
°xiOaFV. 1 hereby xffiSe the I am exempt tram the Cosions Coat
License Law for thio
followW34y whichiromiresm(Secti to 7031.5,Business slter,i improve,demolish,
Co de;Anycity structure
TEMP.MPTF.ROR POLP"INST,
�>,7 which its ism a n germine construct,th alma improve,h permish,or repair any swnward
r$M0 that hor eslicensed pursunttotthe theapplicantof the Co pewit's file aLicense
La satemem POWER DEVICES
QO that he is licensed with
Section the provisions of the Contractor's s;License Law(shaper
ddp� 9(commencing with Smfion]Of10)af Division JoDhe Business and Profusions Code) SWIMMING POOL ELECTRIC VALUATION
or that he is exempt therefrom aadfle basisfordw alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
6 Section 7031.5 by any applicautfor a permit subjects the applicant to a civil penalty of
not more than five hondmi Anllurs($500). NEW RF.SIDIiNTIA1.ELECfR _SQ.FT.
P
❑ I,osownernftheproperty,nrmyemployees withwagesastheiranle compensation, STORIES TYPE CONS'I'RUCI'ION
will do pro work,unit the amours is not intended or offered for sale(Sec.71W4.Business
and Professions Catc:TTe Contractor's License Law does not apply to m owner of
property who builE m lmpmves thereon,end who dean such work himmlf or through his
ownemployeea,providedthatsuch improvements are notlmmndedaroffaced formic.If, OCC.GROUP RES. NITS
however,the buddingor improvement is sold withinoneycarof completion,the owner-
builder .will have the human i f proving chat he did not build or improve for purpose of TOTAL:
rule.).
❑ I,av owner of the Progeny.nmexclusively ramrucit.,with licensed mntranmstn QTY, PLUMBING PERMIT FEE FLOOUZONE APN
construct the project(Sec.]tWq Business and Professions Code:)'Me Contraction. PERMIT ISSUANCE
License Law doe.nm apply to ea ownerof property w he bun Ids or int provas thercan,and
who contracts forsuchprojects with Ammweto pq licensed pureueaunthe Commandoes
License Law, ALTER-DRAIN&VENT-WATE (EA) FEESUMMARY
❑ I um exempt under Site ,B&P C far this mason BACK PLOW PROTECT.DEVICE O iM .E.
SANITARY Y N
Owner Dote RECEIPT g
DRAINS-I1,00R,RO0F,AREA. ND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y_N
❑ ers'Co affirmion Ins nvnceor.icateofca dtmmfOScc.39 nraccNfinm of RECEIIaTN
FlXTLRES-PER TRAP
Wvers 11'Cmploy anon Insurance orettnifi Acopy thereof(Sec.JS(O,Iab CJ which PARK FEC Y N
covers all employ rt ' is.l / GAS-EA SYSTEM-I INC.40U1 RECISION
I'alicyp-7}—l TIUUJ BUILDING DIVISION FEES
ComParty.k GAS-EA.SYSTEM-OVER 4(EA) PIANCHECK PEE
❑ Certified copy is hereby umtshed.
ni0ed copy is fled with the city inspection Division. GREASHANDUSTRL WASTE I RCEPTO GRADING IEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASF,'BAP OILS FEE
COMPENSATION INSURANCE
(This senior need not bemmpleted ifthe permit is for one hundred dollars($100) SEWER-SANITARY-STORMC 200 r BOGY IEE
carless.)
I certify that in the performance of the work for which this permit is issued,l shall WATER I HATER W/VRxPUIBIi
not employ any person in my manner so m to become subject to the Workers' AID
Z Comsati
penon Luwsuf Califomia. Data WATER 1Y1T1OVTREVDNG Dae Rover,,0
Applicant
C NOTICHI 0 APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENf1A1,PI.MB. SQ.f+R TOTAL:
W) become subject to the Worker's Compensation provisions ofthe labor Code,you must
forthwith comply with such provisions or this permit shall be Trimmed revoked. BUILDING FEE
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby offiw that them is a construction lending agency for the performance of
L) C) the work for which this pewit is issued(Sea 3097,Civ.C.) TOTAL: ELECTRIC FEE
(..does Name PLUMBING FEE
U Lender's Address Q'PY, MF-CHANICALPF,RMIT FEF.
1 certify that I have read this application and state that the above information is neN
.1.Iegrecmmmply with ail city aiW munry ominmmand num laws relating to PERMD'IS$UANCE MECHANICAL FEE
E-' Vj buildingeonstruction,and hereby authorize representativesvRhis city to enter upon the
U 7 above-mentioned progeny for inspection puryoses. ALTERORADDTOMECII. CONSTRUCTION TAX
F7 (We)agree to save,indemnify and keep harmless the City of Cupertino against 01
liabilities,judgments,costs and expenses whichmay in any way accrue against said City AIR HANDLING UNIT(TO I0,010 CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER IOd"CFM)
Signature of Applicant/Cunwctor Data EXHAUST HOOD(WIDUCD
PAID
I IAZARDOUS MATERIALS DISCLOSURE - HEATING UNIT 1111,101'11H Data Recciptp
Will the applicant or future building occupant sore or handle hasamous material
as defimW by the Caliendo.Municipal Cade,Chapter 9.12.and the neelth unit Safely HEATING UNIT(OVER 100,(00 BTU) �1 TOTAL
Coda Sexton,0 SSJ2(a)? VENTILATION FAN(SINGLE RESID) PA G
❑Yes ❑No
BOILER-COMP(3HP OR 1(X1,000 BTU) ISSUANCE DATE
mountaWill thin cocumnants its Belding by the Bay equipment orality analleemit JUL O
Didoctus air contaminants its deHncd by the Bay Area Air Quality MlNaggRltOl BOILER (OVER 100,0118 BTU) 1994
ninrin]
❑Y. ❑No NEW RESIDENTIAL MECH. SQ.FT. //ss L'I IY Ur V
urtN u1CU
1 have mad the hazardous materials 5505,25533 under Chapter 6.95 d the
California Health&Safety Cale,have
Sections 25505,2557]and 8534. 1 underntond that
Hi inglines orequirmentscurrent 116nvicetenam,that it is my responsihility to notify the
of tlm requirements which n st act p nr to issuance of a Car
ifcate of
or
r oath zed agent N5W Data TOTAL: ISSUED
OFFICE-