26271 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO •- - rRICAL PFRMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL _ 2 6 2 7 1
BUILDING PROJECT IDENTIFICATION'%'., n.yrc
B TLDING ADDRESS: 1 ~^� SANITARY NO. APPLICATION SUBMITTAL DATE:
I 1 11 • -`V 1 `a l -IhU'NITx LOT
PHONE: M1TRACTv\OWS N'�.i� LIC NO: N/C CONTROI.p
—,c ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE ' 4E4CrTR"I4C S P9ERMOfsItTVdr"t,' w 1
EE
k',-"' 'MMr�BUILDING PERMT INFO
BLDG ELECT PLUMB ME°CHmy. .q =..
PERMITISSUANCE El
LICENSED CONTRACTOR DECLARATION APPLIANCES-RESIDENTIAL
]CZ lhcrdry affirmthatlam licenxdundcrprovmionsofa2pler9(commemingwith JOB DESCRIPTION
-00 Section ofDivision Sof the cosiness and Professions Code,and my License is in PANELS ly�'J'
y V U full forcerce andand effort.
J
<ZL] License Class Lic.a ITP T02W AMPS I
-�<= Date Contractor 201-1000 AMPS
N
—.K ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
Z=.n I understand my plans shall heated as public tecoNs.
_m SIGNS ELECRUCAL
—Ej Licenraed Professional
y
M< OWNER-BUILDER DECLARATION SPECW.CIRCUIT/MISC.
Z) 1 hereby affirm that 1 not se empt from the Contractor's License Law for the c n ^ n
3O ret following reason(Section 7031.5.Business and Professions Code:Any city or cowry TEMP.METER OR POLE INST.
< which tegmms a permit m constmn,alma improve,demolish,or mpav my swcture p _
�� prior m its issuance.almiciluires the applicant for Such farmer to file a signed smrrent POWER DEVICES /t✓r� � p II
z=p that he is licensed pursuanrto the Provisions of the Contractor's License Law(Clupmr
_p 9(commencing with Section 7")ofDivision 3 of the Business and Professions Cade) SWIMMING POOL ELECTRIC 'VALUATION
or Nat he is exem t Ncrefmm and the basis for Ne elle mciere i An i
SO P B pion.Any of OUTLETS-SWITCHES-FIXTURES
-ZT Sec6on703l5byanyapplin iforapcnnitsubjx Ocepticmttoacivilpenaltyof
o &fesaions
Nan five nnnarea aon.rs azW). /
zooowncrofthepropmy,ormyemploy=swiNwagesms eirsolecompn don. NEWRESIDENTIALELECfR _SQ.FT. STORIES TYPE CONSTRUCTION
Cede:The Convenors License Taw does not apply to an owner of
Iwbuildsorimpmvesthereon,and%Mdo suchworkhimalfort ughhis
_ OCC.GROUT' RES.UNITS
cvea.&bs.prvvorimprove is
sold within
nne earofedmpetio ,forsalnq
huilder .ill have
the burimprovementissoldwithinoneyear of completion,Neownen
TOTAL:
builder will nave Ne burden of proving that he did not build or improve for puryma of
sale.). nowt P s
. , a,Pea.'x-` a tie 7
ZONE APN❑ I,avwrofthepmpny. mexclusivdyconvactngwiNlicensdmna,. t �wLMING PERMITYvs I-
,s'va
rsavw'<nartd3�' 7.aitier,[w'L3S
wmwn the pmjact(See.]Bu,Business and Profeasimss Code:)The Convenor's
Limnelaw doesnm applytomownoofproperty whobuildsorimproves thertm,antl PERMIT ISSUANCE
whence Law.ace for such projmts wiNacontncmr(s)liuthe pursuant to in Cctor's
License ALTER-DRAIN&VENT-WATER(EA) �0dp�.. '' S.FEE SUMMARY P` tx `zf
•
❑ 1 am exemps under Sec. ,B&P C for Nis reawn OUTSIDE FEES
BACK FLOW PROTECT.DEVICE SANITARY Y N
Owner Dam REM,PT b
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOL TAX Y N
: ❑ Iherebyaffumthatlhaveace riimeofwmenimalf-imum,oramrtFiutcof — RECEIPTa
y Weakers'Compensation Insurance or a cenifted copy theeof(See 3600,Lab C.)which FIXTURES-PER TRAP PARK FEE Y N
l covers all employee's under Nis permit. GAS-EA.SYSTEM-I INC.4OUTLETS RE-CEIPTM PolicyBUILDING DIVISION FEES
Company x
Cany' -
❑ Genif ed copy is hereby furnished. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cenifed ropy is Bled with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP SOILS FEE
COMPENSATION WSURANCE
(This section need not be completed ifthe permit is forone hundred dollars H100) SEWF SANITARY-STORM EA.2WFT. ENERGY FEE
or Iauj
I cmiify Nat in the perforoanee of the work for which Nis permit is issued,l shall WA (EATER W/VENT/ELECfR
nor employ any person in any manner so as m become subject an the Workers' PAID
Z Comperwtiw Lawsof Caffomia Date WATER SYSTEwrREATING Date Reccipt#
Applicant
i NOTICE TO APPLICANT:If,a1w making thB Canificare of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
^ become subjcd m Ne Worker's Compensation provisions of the Labor Cork,you must
forJrwith comply with such Provisions or this permit shall be trained mvoked. BUILDING ME
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is o construction lending agency for the perfmmmnce of -
- TAL ELECTRIC FEE
theerr,for Much permitrs
is fxmt issuec ed(S3097Civ.C.)
Lend N ,rxs F r. rrz.-'e'rEvu rY_s 'a-y'r'+ "�.
Lena Aaereaa QTY f* tMECHANICAL PERMT� ,� ,-, FEEs'Ff PLUNKING FEE �w
3 LV-.l I certify that I have read this application and sum that the above informationxa_.r. 'k'T'=.Sk,;cj MECHANICAL
-s.aat�rarm n .., v.:tuF'a.-
omct.lagraro comply with all city and county ordhmnccs end stain laws nuaungto PERMIT ISSUANCE MECHANICALME
buildingconavenion, dhercbya apmantionves of this city to cater upon the
(/) CONSTRUCTION TAX
Z aMve-mentioned pmpc y for ins
pe Puryoses. ALTER OR ADD TO MECIi.
(VA apfcc m sav emnif^ted keep hamJess thc City of Cupcnino against
-. liabilUl gmenu.cosu an -h may in my way accrue against said City AIR HANDLING UNIT(TO 10JXS0 CFM)
in consequence of the greeting of this Permit.
I ` /�• � Alft HANDLING UNIT(OVER 10,000 CFM)
wrote of Applic.00ommnmr I m Y/are EXHAUST FOOD(W/DUCTI
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IWAW BTU) Dam Reccipt#
Will the applicant or future building oceupam sore or handle hazvdous mamdal T01'
HEATING UNIT(OVER 100.(100 BTU)
as dcfincd bo the Cupertino Municipal Cods.Chapter 9.1'-,and the Health and Safety
Code,Semi 25532(e)y
11ties ❑NO
licamorfumrtbuildingmcupmt meegmpmenmr VENTILATION FAN(SINGLE RESID)
❑
ISSUANCE DATE
Will theapplicantorfuture devittswhieM1 emit BOILER-COMP(311P OR IIq.000 BTU)pp
hacvdous air cnmumlnams us defined by the Bay Area Air Quali,Managemem BOILER-COMP(OVER 10).000 PTU)
't.District^.
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
- 1 have read the hazvdous materials requirements under Chapter 6.95 of the
California Health S Sale,Code Sections 15505,25533 and 25534. 1 understood that Ai
if the building does not cummly have a tenant,that it is my responsibilily to notify the
mcupam of the reyuiremems which mets be met prior tin isuance of a Certificate of
occupant..
Ownena amhomc l.,,at Date TOTAL: ISSUED BY:
OFFICE GIIY _}r ";!jr