26687 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOIn CAI, PERMITNO.
APPUICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: n SANITARY NO. A/PP�LICATTIION/suBmDTAL DATE
If 24K.. • UNIT# LOT#
OW I 9NS%ME y PHONE CONTRACI'OR'SNAME: LIC NO: NIC CONTROL#
r 4��/-I Z o G� Q
ARCI IN ECI'/ENGI :ER: LIC NO: ADDRESS' ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMITISSUANCF. 11 El El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL �^ l� JOB DESCRIPTION
p02 Ihercbyaffinnthu03 of
fthnseduess sued Preffembers Cords, (commencing with
{+1 es Station701110)andefUivisimn3nf iM1e Business and Fivfcssiom Cade.and my Instate is in pgNBlg
yy f�t full nae Clad effect.
6Z
License Class Conte G6 IIP T0200 AMPS
tiQy Date
Contractor 201-1000 AMPS
Z O'zARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA b/SQ.FT.
CZ-0 I understand my plans shall he used as,public records.
is SIGNS ELECTRICAL
Ca as— Licensed Professional
C 6 OWNER-13UILDF.R DECLARATION SPECIAL CIRCUITIMISC.
X0,F I hereby affirm that 1 am exempt from the Contrecyrs Licerese Law for the
W 3 LLO m¢ following reason.(Section 703 1.5,Business and Professions Code:Any city or county TEMP.METER OR POLE MST.
t�0 J which requires a Permit o construct,alter,improve,demolish,or repair troy associate
;:'^};� Prior to it issumec.idsoreqtrims theapplicnd forstrch perrNuo file.sigruximmmem POWER DEVICES
WOO that he is licensed punumt to the provision of the Contractor's license Law(Cluipter
dp, 9(commencin with Section]000 of 3 ofthe Business add Professions Code SWIMMING POOL ELECTRIC
x� (commencing )o ) VALUATION
yF)Z anhm heir exempt my applicant
she basisforAlegedexemant to civiny l
of OUTLETS-SWITCHES-FI%lURES r ` \
I�ZQ Sedion]03LS by any applicant fare permit subjects the applicant acivil Pendry of I I
?� G not more then five hundred dollars(3500).
❑ I.asowncrofthepmpmy,nrmyemployeawithwagesmt irmiecompemefion, Ni
NEW RESIDENTIAL ELECIR _SQ. kIES TYPECONSTRUCI'ION
a3-2 will do the work,and the stmnureie not inuneedoroffercdfosde(Sec.ID44,Baainas t 61J I� I� "jT i� R
and Professions Cale:The Conuactor'a License Law does nota 1 to An owner of U u
propcny whobuiIdsorimproves thema rand whodoes such workhimselfmthrough his
employees,pmvidMthatsuchimprovementsarcnothnendedorofferedforsde.If, Ol RFS.UNITS
however,the building oro
impverestat is sold within one year of completion,theowner- rTOTAL:
builder will have the burden of proving that he did not build or improve fm purpose of .—
W1e)' QTY. PLUMBING PERMIT FEE FLOOD NE APN
❑ Las r Project
S..7044,Business
add
Cade:)
Th eonwmom to
construct the project(Sec..an. re,.T and Professions Code)The Cermor,mcl
License Lawdoeauch Prlyta ashbo maracpmy whnsed sorimpmves thereon,and PERMIT ISSUANCE
Lived..hoson
For suchprojauwithecommctor(e)liccnsed pomumuothe Convectors ALTER EA
Licenu law. ( ) PEE SUMMARY
❑ I am exempt under Sec. ,B&P C far this anon BACK FLOW PROTECT.DEVICE
SANITARY Y_N
Owner Date DRAINS-FLOORROOFAREACOND. RECEIPT#
, , , .
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN_
• ❑ I hereby affirm thin l have a cmiftcate Mconsent to Alf-insure.ora certFlXIURES-PER TRAP certificate of RECIi1PT#
Wokers'Con,ensntion Insurance o acenified copy thereof7Sec.3800,Labs C.)which PARK FEE Y N
covers all employyeeder s orthis'Ed. RECEIPT#
Policy# :a 03cj GAS-EA.SYSTEM-1INCAOUTLITTS
Company— hed, GAS-EA.SYSTEM-OVER 4 EA) PLANCHECK FEH ILDING DIVISION FEES
❑ Certified copyi hereby famished.
❑ Cenifiedcopyls fled with the city inspection division. GRFASHONDUSTRL WASTE INTERCEPTOR GRADING ME
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This sectionnem not becompletW ifthe permit is for one hundred do]].t$100) SEWER-SANITARY-STORM EA.2011FT. ENERGY FEE
or
I certify that in the perfanrwru of the work for which this permit is issued,I shall WATER HEATER W/VENT/ELECTR
not employ any .n in any manner so as to bcmme subject to the Worker' PAID
z Comperandionlawsof Califomis. De¢ WATER SYSTEM/IREATING
Date Receipt p
Applicant
z 0 NOTICE TO APPLICANT:If.After making this CmiBcals of Exempriou,you should NEW RESIDENTIAL PLMIL SQ,FT. TOTAL:
t-� V) become subject to the Workers Compensation provisions oflhe labour Cade,you must
7 forthwith comply with such proviaionsar this peamitshall be deemed revoked. BUILDING FEE
z CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm thauhem is o construction leading agency for fie performanu of TOTAL: ELECTRIC WE
O the work for which this pc.it is issued(S..3097,Civ.CJ
LI. Iandels Namc
Lcmcrs Address QTY. MECHANICAL PERMIT FEE PLUMBING FETE
V 1 certify that I have read this application and nate that an shove information Is
�-' Go builds lagree mon,comply
and hereby city And county oNinaaccsdns city eanrupon the PERMIT ISSUANCE MF,CIIANICAL FIiP.
F-' Z buildingconstruction, hereby fva widens city roamer upon the
V 7 tMve(mentioned property for inspection loa,ha. ALTER OR ADD TO MECH. CONSTRUCTION TAX
•^. (We)agree to save,indemnify.kap harmless the City of, iter l against
liabilitics,ju mnts,cosuandexpensa whichrrtey inany way a«meugoinst said City AIR IIANULING UNIT(TO Iq(gO CFM)
in con n of the granting oft spermi
(p(��y'� AIR HANDLING UNIT(OVER 10,000 CFM)
Sig um of Appfleant/Contmcyr Da! te MHAUST DOUG W/DUCI)
PAID
HAZARD0115 MATERIALS DISCLOSURE HEATING UNIT(TO 1011,000 BTU) Day Receipt If
Will the applicant or future building occupant store or handle hazardous ntauriW IiliAl'ING UNIT(OVER IW,OfXI BTU) T
u defined bythe Cupertino Municipal Crile,Chapter 9.12,and the l Italia and Safety
C c,Sceti 23532(e)7
13Yes ID No VENTILATION PAN(SINGLE RESID)
❑
Will tbeupplicentorfmurt buildingaccupmt uuequipmem ordevices whichemit
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
hruallous air contaminants as defused by the Bay Area Air Quality Management BOILER-COMP(OVER IW,"B'TU) M !,1 B L)
District? ❑ # A
Yes ❑No NEW RESIDENTIAL MECH. SQ,Ff. R fJ'
1 have read the brzmdous materials requirements under Chapter&95 of the ���
Culiforniullaltb&Safsty Cade,Sectiom25505,255J3and25534. Iuaderstindthm n/r Mt/
if the building does not currently have t tenon,that it ix my responsibility to mn y the 4a f r
occupant of the requirements which must bin met prior to issuance of a Cenificate of Ur
Occupancy.
Owner nr nmhodzed ngent Dom TOTAL: ISSUED BY:
OFFICE