26121 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
QITYOFCUPER'PINO mLVINU n"fuI[m PERMrrSO.
BUILD*NGDIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL rat n
BUILDING PROdECr IDENTIFICATION o 1 L
BUILDING AgDRES a_/V SANITARY NO APPLICATION SUBMGTAL DATE
L/!V„{♦r/6►�pxQ� UNIT# LOfM 2�.Uy�
OWN RS NAM � PHONE: CO RA R' LIC NO: NIC COM—ROIL# l
�ARDIIITEGT/IiNGINEEH: LIC NO: AD ESS. ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT PEI? EUILDING PERMIT INpG
ELECT PLUMB MECH
PERMIT ISSUANCE. El 0 El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB
Metz Ihereby affimuhat l sm licensed underprovisions of Chapint)(commencingwids J
tdt Section force andefUlvisionJof the Business errd Professions Code,and my license is in PANELS ��
,_7ndfullforceClade(T«t.
<y 0- Date Class Car UPT02WAMPS
AMPS
N 6 y Dote Contractor 201-1000 AMPS
S yZ_ ARCHITECTS DECLARATION OVER 1000 AMPS SQ.PT.FL R AREA SISQ.Pr.
O'L O 1 understand my plans shall be mM as public rewrda.
SIGNS ELECTRICAL
Q�beQ Licensed Professional OWNER-BUILDER DECLARATION SPECIAL CIRCUTT/MISC. Iny�`B
x1R'OaF I hereby from that 1 am exempt from the Coronations License Law for the 8 Y V
[v131s.yafollnwingronsoi.Ocadnn X31.5,Nosiness enJ l4ofessinna Code:Any city or county TEMP.MEIER OR PO TOS
F J>.. which rryussu a prnnit re c ins,thi' star improve,demolish,m repair any sacrum a�
>� onoia issuenm,also - thea Iicant Ter such mduo file a.i Low
POWER DEVICES
u] prior'. requim PP P< gn 1
<p ohm he is licensed punuanno the provisions of the ConuaaMa License Law(Chapter
0. ❑ 9fconmen' with Semiun]0010 fDivision3ofNe Businmsamd Professions Code) SWIMMING POOL ELE IC
no, omg wi )O ��s� VALUgVyy`1�
i r or that ion 7031.5 by any amerefirpplicant
the basPermfmthets the aexemption.Any ivilpeadon of OUTLETS-SWIT ES-FI)Oy9sfgE yl ��, a/
f. T Sa:oion]W LS by any applicant fora permit subjects the aPPlicantmacivil penWyo(
of n e than five hondre dollars(5500).
p Losownerof lhepropeny,ormyemployeee wiihwagessstheireOlecompemmi... NEW RESIDENTIACCECECTR _SQ.PT. STORIES TYPE CONSTRUCTION
Is. will the work,and the vrmmmisnmt intendedmrorc<rW forsele(S«.]t14a,Bosiness
end Prix essioas Code:The Contractors License Law does not apply to an owner of
propenywhobuildsor improvesthemon,and who does such work hirraelfor through his OCG GROUP RES.UNITS
ownemployeen,provided Rod tsuch improvements arenotimendedorofferedforsale.If,
however the building or improvement is sold withimoneyesrofcompledon.Incision.
builder will have the burden of proving that he did not build or improve for purpose of TOTAL:
solo.).
❑ I,osowner ofthe property,son eaclusivelyconvacting with licnctal connectinto QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
O..tram the preject(Sec.7044,Business and Profession.Cade:)The Convectors PERMIT ISSUANCELi censeLaw does not appl y tO m owner O(property who bui Ids or improves Hereon,and
whocontransfor such prujectswith a contnctor(s)licensed punuantto the Connectors pLTF,R-DRAIN&VENT-WATER(EA)
License Law. FEE SUMMARY
❑ I tun exempt under g«. .B&P C for thu reason BACK FLOW PROTECT.DEVICE SANITARY Y DE N
Owner Date DRAINS-FLUOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Ihereby affirm thetlhav<r mnifi<eaofmnsenuo self-ivurt.ora«nificam of FIXTURES-PER TRAP RECF.IPI'#
W«kers Comprommn lnsuraneemacenifiedcopy themof(Sec.38100,Lab C.)which PARK FEE Y_N
seders all employee'sunaezlhisp<rmit. - GAS-FA.SYSTEM-[INCAGUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Ceri6edcopyisherebyfamished.
❑ Certified Copy is filed with the city inspection division. GREASFYINDUSTRL WAS'IT INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section n«d not he completed ifthe permit is future hundred dollars(SIM) SEWER-SANITARY-STORM F.A.2mrr, ENERGY FEE
or less.)
I cenify that in the performance ofthe work fm which this permit is issued,I shell WATER PRATER W/VENTIELECIR
not employ any person in any manner so as to become subject to Ne Workers PAID
Z Compensation Laws Of Coliform.. Date WATERSYSTE LIREATING Date Receipt#
Applicant
412 NOTICETO APPLICANT-.If.afe,making thio Certificate of Exemption,yam should NEW RESIDENTIAL PLMB. SQ.FT.
T L:
T-� 00 become withco«ty the such
Compensation ermitshouook oftnerned revoked. most
�i
forthwith comply with such provisions or this permit shall Na deemed revoked. BUILDING FEE,
0. (� CONSTRUCTION LENDING AGENCY SEISMIC FEE
U Z Ihereih
byaffirmm them is.....iN <nd
uon lmlitienth
cy for e performance of TOTAL: ELECTRIC FEE
tho work for which this permit is issued(Sec.300,Civ.CJ
Lender's Name
0 U Lenders AM.. QTY. MECHANICAL PERMIT FEE PLUMBING PER
1 emery ohm 1 have rad this application and mare Net the above information is
correct.l agme to comply with all city and county courtroom and state laws relating m PERMIT ISSUANCE MECHANICAL FEE
W
' i,i buildingcroswcoon,md Mmbyauthodzempmsenauvesofthiscitywetneruponthe
V Z above-mentioned property for inspection purposes. ALTERORADDTOMECH. CONSTRUCTIONTAX
I Wel agree to sa unify and kap harmless Ne City of Cupertino against
liubilitics,judgn ndexpemses which may in any way accmeagainst said City AIR HANDLING UNIT(TO IOp00 CFM)
inconsequent n -renting of this pminit. AIR HANDLING UNIT(OVER 10,0410 CFM)
A 17-1 A
Sign r r pylic d nmamr Date CXHAUS'fHOOD(W/DUCT)
PAID
AZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dote Receipt
Willi pliant or future building«cre fourn soor handle hezordaus material
y the Gupcnino Municipal Code,Chapter 9.12,and the Health and Safety IIEATINO UNIT(OVER 100,00X1 BTU) TOTAL:
Caac,Section 23532(a)1 VENTILATION FAN(SINGLE RFSID)
❑Yes ❑No
aJCAD fE
Will the applieantorfuture building«cupant use equipmentordeviceswhichemit BOILER-COMP(311POR IW,INX)BTU) ISSU Dtrin? g1
zmdous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)ex9nn
❑Ycs 11 No NEW RERESIDENTIALMF.CII. SQ.Ff. gI)I^AR 9
0
IJJ
1 have read the havrdrua materials req1994
uimments under Chapter 6.95 of the
Coliforms Healths,Safety Code.Swions
on,thi it I, a, cap... 1ity maand that
if.....tiding rima no,cserenly have a most
he,ohm d is no, capof mty a notify Ore 1
Occupant of the rtyuiremems which mus rte met prior m issuance of a Certificate of
Occupancy.
Owner or authorized agent Doo - TOTAL: ISSUED BY�
OFFICE