26346 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOISUILDING-ELECTRICAL. PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL A C
BUILDING DIVISION IIUILDING PROJECT'IDENJ'IFICA'1'ION4 v'
BUILDING ADDRESS' - y� / y�`//y SANITARY NO. APPLICATION SUBMITTAL DATE
p( /—A (../ITr/ G UNIT# LOT#
OWNERS NAME: (' / PHONE: CONTRACTOR'S NAME: LIC NO:
LGN {,f{/ (/ [.b l U 2U -/z
NIC CONTROL#
•ARCI Tlj /ENGINF..R: LIC NO: ADDRESS:
r rf��la i 911 c iceow 45eev4✓
CONTACT: PHONE: BUILDING PERMIT INFO
KnVUA/OUN qtf- // QTY. ELECTRIC PERMIT FCC
.6vic J �(A/_ 20z iLUF ELIiC'I' PLUMB MECH
PERMIT ISSUANCE If_�V[d � � ❑
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL
plyz I hereby affirm that l am licensed underprovisions of Copter9(commencing with JOB DESCRIPTION
E100 Section 70(1 Division 3 ofthe Business and Professions Cade,and my license is in PANELS
fullfo�ce and cIT
<j" I.1ceau Class Lic.# 07U°lL UP102MAMP5 v✓
,;i E: Date Cona, r F ✓ L 201-LORD AMPS
F,z ARCHITE DECLA ATION SQ.FT.FLOOR AREA $ISQ.Ff.
Z'z'" lundemand des public records. OVER LBW AMPS
PynLtq SIGNS ELECTRICAL /SvI� ff Oleic
<Y�""I LiccnsW Professional
%C)wu
OWNER-BUILDER DECLARATION SPECIAL,CIRCUIT/M 32L/1'/J f'f OT/�IN a
X'Oy V hereby affirm that I am exempt from the Contractors License Law for the
vFi following mrson.(Section 7031.5,Business and Professions Code:Any city or county TEMP.MET ER POLF NST.
F �< which requires a unit to construct,aller,improve,demolish,or repair any aloacterc �6 lyFh �i Zt7J
$�Y� to its issuance,also re the applicant for such lto file a signedstatement POWER DEVICES
prior quires pp perm
�m�0 that he is licensed pursuantto me provisions of the Connector's License Law(Chapter SWIMMING POOL F.LECRtIC
e.aoF5 9(Commencing with Section T)00).f Division 3ofthe Business and Professions Code) VALUATION
^y or that he is exempt therefrom and the basis for the alleged exemption.Any violation of
FZQ Section 703 L5 by any applicant for a permitsubjects dmit,,liwu
mo a civil penalty of OUTLETS-SWITCHES-FIXTURES U)
E=0 not more than fiv<hundrM dollars($500). NEWRESIDENTIALGLECIR SQ.FT. STORIES TYPE CONSTRUCTION
CF. ❑ I,asowncrof�cpmo ny,ormyemp)oymswithwaguwtheirsolecompeasat n,
yam rill do the work.andthe s0ucmreis not intended oreffered for wale(See 71HO,Business
and Professions Cale:The Contracmr s License Law does not apply to an owner of
property who builds or improves thereon.and whodoessuchwod nonselforduough Ns
Jedthat mcb int ememsart notimendedoroffened f.rsale.If, OCC.GROUP RES.UNITS
crop ees.pmvi pmv
however,the building or improvement is sold within one year efcompledear.for the owner- TOTAL:
h lJ Ilk henh J fp gIn.,h JJ tb Id improve for purpose of
:IeJ
❑ I nor ol the property, c ly Contractingwith commons,in
onnetorsto QTY RIPLAUNMC}B'nnINGffhh��Q�SF1
FLOOD ZONE APN
ocinxt t(lie amiject(S 7fluaBa"rmsx and Professors Cole)no Contractor's
Licro,c Law does cutapPlYtoan I h 'IJ:nmprnvesHeeon,and 'GMTISSU
y�yl�i1I Is
hocontracts f r: chprojects with a contra t ()licensed pursuunuothe Conaaaors I,'J)s`(1 mow- d
lice Law. ALTIiR DRAIN" 1) "� EEE SUMMARY
❑ I um exempt under Scc. ,B&P C for this reason HACK Flo �� J`� _L IITSIUE FEES
SANITARY Y N
Owner Data AINS-FLOOR.ROOF,AREA.COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
-❑ IM1ereby aff that l have acenificateofcomannoself-insure,mamnificzteof FIXTURES-PER TRAP RECEIPT#
Workeri Cnmpensaion Insurance.,acenlfied copy Nemof(SsC.38130,lab C.)which PARK FEE Y N
covers all employee's under this permit GAS-EA:SYSTEM-1 INC.4 O RECLIPf#
Policya n n BUILDING DIV 151 N FIEJU
Company GAS-G.SYS LM OVER'4 EAJ`. O_-.. L� ./ t PLANCHF.CK FEE
❑ Certified copy is hereby famished.
❑ CenilicJ copy is fled with the city inspection division. GREASWND TRI WASTE INT R B GRADING ITE _
CHR'TIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
('Mismeion need not be completed lithe permit is for one hundraddellm,($IW) SHWER- ANITA ENERGY FEE
or less.)
I cenifythm in me wharnance of the work for which this permit is issued.Limit WATER HEATER WNENT/ELECTR
not employ any person in anyyyyyyIllIIImaare,/�o subject t.the Workers' PAID
Compensation laws of Cafi YWATER SYSTENV REATING Date Receipt#
O z Applicant O0/�
z O NOTICE TO APPLICANT:If.after making this Ceni&ate of Exemption.you should NEW RESIDENTIAL PLMB. SQ.PP. TOTAL:
(" ^ bcesme subject to the Workers Compensation provisions M the Labor Cade,you must
> forthwith comply with such provisions small or this permit all be deemed revoked. BUILDING ME
. S SEISMIC FEE
Q. [� CONSTRUCTION LENDING AGENCY
z IM1ereby affirm that hem is a construction lending agency for the performance of TOTAL: ELECTRIC ME
U O the work for which Nis .it is asued(Sea 3097,Civ.C.)
I coda's Name
LrPLUMBING PER
F Lenders Ardor, QTY. MECHANICAL PERMIT FEC
V 1 cenily that I nove real this application and cerate Ohm the ahnve information is
W correct.Iagrec m comply with all city and county ordinances and sone laws relating to PERMIT'ISSUANCE MECHANICAL F131i
f" V) building Construction.and hereby aumoriu mpremamoves ofthis city to enter upon to
V CONSTRUCTIONTAX
Z abswcanentlnned poi for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to cave,indemnify and keep harmless the City of Cupertino against
Iiabilities.judg,nems,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO I o,WO CFM)
incense a of the granting ofthis permit.
AIR HANDLING UNIT(OVER 10.0)0 CFM)
Si mote of APdicaacConuaelo, Date EXHAUST HOLD(W/DUCn
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building occupant store or handle hazardous material
as defined by the Caisson.Municipal Cale,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,090 B-I'Of TOTAL:
Code Section 25532(u19 VENT[LA'I'ION PAN(SINGLE RE$ID)
❑Yes ❑No
W ILER-COMP(3HP OR I W,(10t1 BTU)
ISSUANCE DATE
Will NctPPlicunt or future building occ.pam usceyuipmem nrdevices which emit
�Lavvdous air contaminants as defined by the Bay Arca At,Quality Management BOIL fi -COMP(OVER 100,1100 BTU)
Di alter: A
❑Yes ❑No NF,W RESIDENTIAL MECH. Sp.FT. I'�q '
1 have mad the has, ..a materials moicircmenn under Chapter&95 of the O
California Health&Safety Code,Sections 25505,25533 and 25534.I underetaad Nat #'/ftj
(�
if the building docs not cummdy have a tenant Ohm it is my msp.maibddy m notify to S
secupam of the ne9uiremems which must be met prior m issuance of a Certificate of �9!l 9
Occupancy. Y
Owner nr authorixed agent Date TOTAL: ISSUED Bfeh'
OFF