26059 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINORII......NfrR17. A" PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 26059
BUILDING DIVISION HILII,DIN'C.PRUdRCf1DEN'1'IFICATION
BUILDIN]G/A/MDLI�RILSS: SANITARY NO. APPLICATION SUBMITTAL DATE
L V �l ��
OWNI. UNITN LOT
AME: ^ YHOONE: NT ACTO 'S NA ': LIC NO: NIC CON'IKOLM
RCHITECT INEER: G LIC NO: AD RESS ���
u e1 f0
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE _i
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL `-�
❑etZ Hwo,byaffinnthail am licensed under provisionsofChapter9(commencingwiH LOB DESCRIPTION
WOO Section 7")of Division 3 of the Business and Professions Code,and my license is in PANELS
F C[ full farce unit effm
=,W E UP TO 20JAMPS
�Qd hlcc�Cl s COnrraz-�h 201-IOW AMP3
F'Oy ARS ARCHITECTS DEC RATION r SQ.FT.FLOOR AREA SISQ.FT.
z c y— OVER 1000 AMPS
OL_❑ lunderstanJ my plana shell be used rccoMa.
SIGNS ELECTRICAL
Fro ;
Liccr,ed P..fir.,l...I
K ot< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
X 'e. I hereby affirm that I am exempt from the Contractors License Law for the
m 3 is-�F2is following session.(Section 7031.5,Business and Ponfessions Code:Any city ser county TEMP.METER OR MILE INST.
F y.0. which requires a Permit to construct.alter,improve,demolish,or repair any structure
�W}:j: prim,nexis....Cc,alsoreyuirevthe applicanfor such fa mtm0/ tedowannew POWER DEVICES
WK aQO that he is licensed pursuant to the provisiews.(the C.M." ., sew(Chapter SWIMMING POOL ELECTRIC VALUATION
e.E: 9(commencing with Seconn 7000)of Division 3 ofthe P -- ,.mmm Cade)
W❑y or then he lS excmpuhomfom and the basis for th,a" �..-Anyviofidum.f �
F,yY
See on 7031.5 by any uppliCwt for ape.it•'� "r ) <mum.eivilreasityof OUTLEI'g-SWITCHES-FIXT11RE5 (�
6 notmo.offim five hundred dOlars(S500e -_s �
W ❑ ,J NEW RESIDENTIAL ELE= _SQ.FT. S"TORIES TYPE CONSTRUCTION
m ❑ LasownwCfdupropmy,ormye='r{ �,_. ge,utheirsolecompensedon.
y3— will do the work,and thestracmmista, "rofferd far We(Sm.7044,Business
and Professions Code:The Contractors L',ame Law does not apply to an owner of
property whobuildsor improvesthereon,andwhodoessuch work himselforduough Ns DEC.GROUP RES.UNITS
employees,prov i dd thm... improvements are not i mm�dd or.f(ered lm sale.If,
h waver.the building or improvement is sold within one year ofcompletim,theovener-
builder will have the burden of proving that he did not build or improve for purpose of
QTY. PLUMBINGPERMIT FEE FLOOD ZONE APN
❑ Lus owner ul'Hu prnpery,wn aolusively umtrae0ng with licence)comrccntr,to
onsruct he project(Sce.7044,Business and PmfssionsCode:)The Comments',
License Law doesnot apply loan mencroPrepeny whobuilds mimprovu Hereon,antl PERMIT ISSUANCE
whecontractsforsuchpmjcmwiHaconv wr(s)licensdpursuattu He Contmcvrc s ALTER-DRAINA,VENT-WATER EA) - MESUMMARY
License law.
C] m 1 aexempt under Sec. .B&P C for flus reu.n BACK FLOW PROTECT.DEVICE OUTSIDE.FF.E
SANITARY Y N
Owner Dat° DRAINS-FLOOR.ROOF,AREA,COND. RECF.IPTp
WORKMAN COMPENSATION DECLARATIONwe� SCHOOLTAX Y N
❑ I hereby affirm that l have a Certificam ofemscal Mself-insure.ma cenilicate of tes1 URES�F.pyrRA RECEIVI'k
Workcrs'Comeemattion Insurance or acenified ropy ehereef(Sec.38W,Lab CJwhich PARK FEIi Y N
IVECEIPT b
era all employma oder this permit GAS-EA.'SYST MJ INC��OUTLETS,' B IVISIONP.ES
Policy g — _ e1 �,
Company tl,�S_-EA,S:Y TEM-OVr Aq�) B PLANCHRCK
❑ Cer ifid copy is hereby fumishd. F I'
❑ Certified copy is riled with He city inspection division. OF
NDUS R GRADING Fl:'
CERTIFICATE OI'EXEMPTION FROM WORKERS' '__ GNIiASE -J SOIL :E
COMPENSATION INSURANCE
(This Sermon need not be completed if He permit is Forcing,hundred dollan(81W) SEWER-SANITARY-STORM IIA.20111'. ENERGY FEE
(certify that in Hep to any., of Hewes for which this bject to de,Workers WATER IIPAT[R WNENT/GLECTR
not employ any person li any . Date as u to became subject to the W.hcrs' PAID _
Compeawuon taws of Califomie. Date WATER SYSTEM/IAFATING Daf< '<i1nM
O z Applicant
z0 NOTICE TO APPLICANT:If,after making this Cerifiwm of Exemption,you should NEW RESIDENTIAL PLMB SQ.FT. TOTAL:
� !q become subject to the Workers Compensation provisions of the tabor Code,you must
forthwith comply with such previsions or this permit shall be thermal revoked. BUILDING FEE
6. ❑ CONSTRUCTION LENDING AGENCY SEISMIC FEE
0" z I hred affirm em is a Construction leading agency for He performance of
U O He work for which this Permit is issued(Sec.3097,Civ.C.) ELECTRIC ITE
Leaded.,Name PLUMBING FEF. ./
Lender's Address QTY. MECHANICAL PERMIT FCC
U I certify that 1 have read His application and smm Hat the above information is MECHANICAL IPE
7" II.1 Corect.I grcemctrmply with all city andeuuntyoNinances andsmrc laws relating m PERMIT ISSUANCE
building construction,and hereby amhonzerepresenwtives offhis city toen¢r upon He CONSTRUCTION TAX
Uz aMwcmcntioned property for inspection pugarzes, AL3'17R OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless He City of Cupenim against
liabildies,judglpcmat.elsnnd expenses which may in any wa acauaraginstsoid Gey AIR HANDLING UNIT(TO i0.000 CFM)
in con urn 0,data grunting of His it.
AIR HANDLING UNIT(OVER 10,000 CFM)
Sig azure of Applicw4Commct D EXHAUST HOOD(W/DUC11
PAID
HAZARDOUS MATERIALS DISCLOSURE HEA9'ING UNIT(TO 100.000 BTU) Dam Receipt If
Willeho.ppliettruo,MOO,building occupant mv,o,handle h...Nouamutwial HEATING UNIT(OVER I010,000 BTU) TOTAL
as defied by the Cupertino Municipal Code,Chapter 9.12,and the Health and Salcey
Code.Section 255321.0? VENI'ILA'I'ION FAN(SINGLE RISID)
ElYes ❑No ISSUANCE DATE
Will Heapplicwmrfummbuildingoecupam uueyuipmentordevices whichemit BOILER-COW YHP OR 100.000 BTU)
haevdom yr conmminams as defined by the R.Y Amu Air Quality Management BOILER-COW(OVER 100.000 BTU) PAID
iy 0
❑Y. ❑No NEW RESIDENTIAL MECIL gQ.FT.
1 have read the haaardou,materials requirement.,under Charter 6.95 of the APR 2
❑Oifomla Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that /]
if the building does not cmmatly have a benam,that it is my respomibility 1.notify He 7
occupant of He nermicmrnts which most he met prim as to..of.Cerifieaee.f CI1 y V,
Occupancy. � .1 IIIV(J
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE