26017 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOilins,IIJN(r .EI PERMIT NO.
APPLICATION/PERMIT PLUMBI%G-MECHANICAL N' 26017
BUILDING DIVISION - BUILDING PROJECTIDENTIFICATIO
BUILDING ADDRESS: �s�sy�/ i_- SANITARY NO. APPLICAT10NSUBMI'TALDATE
2UNrIM LOT# I
OWNF, 5 AME: PITON' CONT 'OR'S NAME: !!7
CUAJ6 '� - N.S UL/9 V/Nl -(pry NIC CONI'RQL#
•1RCHITECOENGINEER. # LIC NO: ADU
Z/2/L LOrr+lfa /,4 r ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
@LDG
ELECT PLUMB MECH
PERMIT ISSUANCE L b" ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DF.SCRIPI']ON
piatZ I hereby affirm that l am licensed mocrprovisionsofChaper9(commencing with
WOO Section?")of Division 3 of the Business and Professions Code,and my license is in PANELS
y�1E- full force and effect. u)
VCJ �37'yLZ UP TO200AMPS rJ1-Vf`/N4/1
¢Zti1 License Cl s Li<.p
b-cO Dae Conuacnor 201-IfMXI AMPS S FT.FLOOR AREA S/SO.FT.
7ONZ, ARCHITECTS DECLARATION OVER 1000 AMPS Q
OZ-0 I understand my plans shall be used as public records.
F VsF W SIGNS ELECTRICAL
<, 5_1i Licensed Professional
K �Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
C
X O y V 1 hereby uffrm that 1 inn exempt from the Contractor's License law for the
Wit fullm intlorson.(Section]031.5,Businessend Professions Ccdc:Any cityoromm, TEMP.METER OR POLE INST.
F I��; which requires a permit m construct,alter,improve,demolish,or repair any structure
fW}2 prior to its issuance,also requires the applicant for such Permit to file a signed statement POWER DEVICES
j C<O that he is licensed pursuant to the Provisions of the Contmaors License Taw(Chapter S WIMMDJG POOL ELECTRIC
P'Xo� 9(commencing with Section 7")ofDivision 3 ofthe Business and Professions Code) VALUA'fjQ,'s�
-y or that he is exempt lherefmm and the basis forthe alleged exemption.Any violation of OUTLETS-SWITCHES Fla111RES C��
FZa Section 7031.5 by any applicant for a permit subjects the applicanuoacivil penalty ofit
S=O had me Nanrmthelhundred dy.ormyempl NEWRESIDENTIALELECIR SQ.FT. STORIES TYPE CONSRUCION
KFp n❑ I,asownerof Nepropcny.ormydmployeeswiN wages as Neiranlecompensation, r
W will do the work,and the structure i.snm inendetoroffered for sale(Sec.?0,,l,Business �� /n I �^k (�
and Professions Code Flat Contractor's License Law does not apply to an owner of 1 x \ ` lN'�l0
mmeny who b.ddsorimproves flarown,and wbodoes such work bimselforthroughhis
own cmpoyee,provided that such improvements arenot intended oroffcrcd forsale.If, i-w 1- 'n\O{LFR UP UNI S
howevcrlNe build in got improvement is sold within one yearofcomplefion,Neowner- L 1 I 0 t/0 II� E R
builder will have the burden of proving that he did not build or improve for purpose of
.ala.). QTY, PLUMBING PERMIT FF.E Ft 'o, APN
❑ Las ownerOfnhe propeny,amexclusively convening with liumedconlmctorsto
construct the project(Sec.7044.Business and Professions Cade:)The Contractor's
Licerm Law does not apply to an ownerofpropcny whobuildsorimproves thereon.and PERMIT ISSUANCE.
who contracts forsuch projects with a contractor(s)licensed pursuant to the Contractor's ALTER-DRAIN&VIiN'1'-WATER haeme Law. (EA) FEE SUMMARY
❑ 1 am exempt ondcr Sec. .B&P C for this rcamn BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Date RECEIPT p
-
WORKMAN COMPENSATION DECLARATION DRAINS FLOOR,ROOF,AREA,COND. SCHOOLTA% YN
❑ I hereby affirm that l have a cenificare ofemosent to self-imure,tar a certificate of RECEIPTp
orkers'Compensation Insurance macenified copy therrof(SmJ800.Lab C.)which FlXTURES-PER TRAP PARK FEF. YN
r
coven all employee's under this Permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy 9 BUILDING DIVISION MEN
Cutup., GAS-EA.SYSTEM OVER 4(G) PLANCHECK FEE
�Ccnified copy is hereby famished.
❑ Cerbied copy is filed with the city inspection division. GREASFANDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed iftbe permit is honest,hundred dollara($IW) SEWER-SANITARY-STORM EA.300FT. ENERGY ME
or less.)
I certify that in the perfomunce of the work for which this Permit is issued,l shall WATER HEATER WNENTIELECTR
not employ any person in any m as to become subject to the Workers PAID
Compensationlawsof Califomin. Date m WATER SYSTEMnRFATING Date Receipt#
' O O NOT'ICEtTO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLM B. SO.Fr. TOTAL:
DO become subject to the Workers Compensation provisions ofthe Labor Code,you must lip E;
� > forthwith comply with such provisions or this remain shall bI:
e deemed revoked. BUILDING IF
I.
6. (� CONSTRUCTION LENDING AGENCY SEISMIC PC
VZ I hereby affirm that Nee is a construction lending agency for Ne perfomunce of ELECTRIC FEE
O the work far which this From,is issued IS-309).Civ.CJ
Lendees Name
Leader's Address QTY. MECHANICAL PERMIT FEE PLUMBING ITE �-
U 1 certify than 1 have read this application and stn r then d e above information is
correct.l agree to comply with all city and a
county ordinances and slate laws retailing to PERMIT ISSUANCE l' MECHANICAL FEE
F-' huildingrnnsvuction,and hereby aathorim representatives ofihis city restructured the CONSTRUC'I'IONTAX
U Z above-mentioned property for inspection purposes. ALTERORADDTOMECII.
(We)agree m xav Jcmnify and keep harmle: a City of Cupertino agairet
liubilitics,judgmen' uslr wdc.For— whichm ymermsgametsaid Ciny AIR HANDLING UNIT(TO 10AMCFM)
cnnseque ceo egraming oft .11 _ _
AIR HANDLING UNIT(OVF,R 10,000 CFM)
SignamofAFpJmxmx6mtmcmr I Date I E%HAUST HOOD(WIDUCD PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,00(1 BTU) Date Receipt# j
Will the applicant or future building occupant store or handle hazardous material TOIAL
rat -dined by the Cupertino Municipal Code,Chapter 0.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU)
Code,Section❑Yes 4(a)r ❑No VEN'ULA'I'ION PAN(SINGLERESID) g
ISSUA, E DATE
Will the applicantcr future buildingBOILER-COME(31 IF OR IW,000 BTU) P p
occupantuu equipment-devices whichemit 1"
1-students
comediennes as defined by Nc Bay Arca Air Quality Management BOILER-COME(OVER 100.000 BTU) l/
orict? Ae�-
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.ET. A/Y
1 have read the harnrdo s materials requirements under Chapter 6.95 of the ZS// ,Y as 7994
Culifamia Health @ Safwy Cade,Serious 25505,25533 and 25534. 1 understand that y �'
If dm building does not currently have a tenant.Nro
at it is my regnvibility to noddylhe U1,
rcuIxed m the regaimmeas which maxi he met Print to ivmanec of a CenlBerec of Ohl/IVC
occapamy. .
Owner oremhmiuA a gent Date T ISSUED BY:
0FHCh