26395 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OFCUPF,RTINO _ PLUMBING-MECHANIC 1. PI:Rmn'No.
APPLICATION/PERMIT rING PROJECT
IDENN'IFIC
BUILDING DIVISION III111.UINC PRUJF.CI'111RN'1'IFICA'1'ION '
26395
HUILDING ADDRESS: i SANITARY NO. APPLICATION SUBMITTAL DATE
aao 13 IQ C 7 UNIT# 1.010 ��� l
OWNERS NAME PHONE: (�/ CONTRACTORS NAME: LIC NO:
c�_
kY {.Y,J 11 ^}d{>z (� - ` pC .—? N/C CONTROL
JiARCH[fECT/ENGINEIZR: r LIC NO: ADDRESS: &v' VLW— f V Z`
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MliCfi
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES.RESIDENTIAL JOE DESCRIPTION
Ihembyeffiotvbmlmnliconxd underprovlsloreol Chapmr9(oommencingwith
FOO Section r eland effect. nn i of the Businessand Professions Code,and my license is in pprygLg
CU� Liecroe lasseffect
FZW Date.Class Contractor
UP T0200 AMPS
rn G N Date GOnuacler 201-1000 AMPS 1
ZONZ ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR REA $ISQ.IT.
O Z—C I understand my plans shall be used as public records. � I1II �1yf _
W SIGNS ELECTRICAL L'
j Licenxd Professional
N r^^
6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. ( , J
XOyU I hereby sfrmt Olin 1 um exempt from be Convector's License Law for the )) II l'�
{i]34yq following releon.(Seadon]03IS.Business and Professions Code:Any city.,,.only TEMP.METER OR POLE IN �' !
�,,i which requires a permit m construct,alar,ireprovq demolish,or repair any awnurc r
K�Q$ Iris,toI.issuance,mso regaims me.pplisant for such permit to file.signed statement POWER DEVICES
W W O that he is licensed pursmm m me provisions of the Comrumr s Licenx 4w(Chapter
9(commencing with Section 7")of Division 3 mum Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
W_y or that he is exempt therefrom and the basis for the alleged exemption.Any violation of — app
i- Section 103 L5 by any sued cmtfor aPermit subjects the applicantmncivilpenalty of OUTLETS-SWITCHES-FIXTURES Z�Uo
of mom than five hundred dollars($500).
tY 1 y,nrmyempinyceswitb wugcsastheirsolearmpcnsntion, NEW RFSIDENTIALELECTR —SQ.Ff.
❑ I,nsowncroftha vo tan STORIES TYPECONS"1'12UCTION
will do dm tions Cod the he Co a isnor s License
Low
does not apply to
heowner of
pho impmvestreon,vwhodoessuchmrt ghhis
)wnmploe,providedthnsuchimprovemnsmnotintendMoroffemdforae
If, OCC.GROUP _ RES.UNITS
however,the buildingor improvement is sold withinoneyearofcompledon,Ne owner- TOTAL:
builder will have the human of proving that he did no build or improve for purpose of
suleJ.
❑ Las ownerofthe property,am exclusivelycomracting with licensed cuntralorsto QTY. PLUMBING PERMIT FEE - FLOOn LONIi APN
minlaProfessions a(the project(Sec,11W4,Business d Profesns Code:)The Convector's
coiccnsel.awdeesnm apply to anownerofpropeny who buildsor improvestherwnand PBRMITISSUANCE
whoceiracts for such projects with acnnciator(s)licensed pursuartothe Comructora
License Law. ALTER.DRAIN&VENT-WATER(RA) FEESUMMARY
` ❑ 1 mn exempt under Sec. ,B&P C for Nis reason BACK FLOW PROTECT.DEVICE. SIDE EE
SANITARY Y N
Owner Dam RF.CF.IPTp
WORKMAN COMPENSATION DECLARATION DRAINS.Fh(>nR,ROOF,AREA,COND. SCI{OOLTAX YN
❑ Thereby uffinn that(have accrtifcam of conxm mxlf-insure,oracenificau of FIXTURES-PER TRAP RECEIPT#
Worken'Cnmpensation lnsurvnccoracertified cnpythemof(Sec.380o,LUF C.)which PARK FEE YN
rosins all employee's under his Permit. GAS-EA.SYSTEM-I INC. OLD 1.II'1'S RECEIPT#
Polley# HIJ I LDING DIVISION FEES
Company GAS-FA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cenifird copy is hereby rumished.
❑ Certified copy is That width Ne city inspection division. OREASrVINDUSTRL WASTE INTERCEPT OR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE'IRAP SOILS FEE
COMPENSATION INSURANCE
('Ibis section need not ba completed if Ne permit is forone hundred dollars($100) SEWER-SANITARY-STORM EA.2001T. ENERGY FEE
o Ices]
I artily that in thepannmmer.fthe work far which this permit is issued,Ishnll WATER IIl,,,rRWryENT/ELEC'IR
not employ any person in any manner so�§s ggmm bject to the Wdons PAID
C.mtanouionlx� of lifotd.. Dam TJ/R 9y au WATER SYSTEM/IREATING Data Receipt#
st
NOTICE TO APPLICANT.If.aftermakingmelting tthis Certificate of Exemption,
zyoou..d NEW RNSIUCNTIAL PCMB. SQ.FT. TOTAL:
(A becorne hwithejce empt1.hey
Wnrkeh Compensation ermisinmofeheemed Cooked. must
forthwith comply with such provisions or this permit shell be deemed revoked. BUILDING FF.F, Y/ r �119C1
Q CONSTRU10N LENDING AGENCY SEISMIC FEE ! f
1 hereby affirm that hen is a construction lending agency for the perfmmance of
U O ma work for which this permit is iutu ed(Sea.3099,Civ.C.) 'TOTAL: ELECTRIC FEE
Lender's Name
0 V Lenders Address QTY, MECHANICALPERMIT FEE PLUMBING FEE
1 really Not 1 have read this appliwtioo and also,that Ne above information is MECHANICAL FEE wrrcct.(agree mcomply with all city and c.umy oNinanco vnd stem laws mletingm PERMIT ISSUANCE
F' D, baildo,ommrmmian,and herabyruidamze repmsenlstivesufthis cityro anrrupomM1a CONSTRUCTIONTAX
U Z .have-mentioned pmpeay,(or inspection p rim us. ALTER OR ADD TO MECH.
(We)agree m save,indemnify and keep hnrmlem the City of Cupertino against
Ilandiliee,judgments,costvund expenses which may in any way earmeagainstsaid City AIR HANDLING UNIT(TO 10,00)CFM)
in consequence of the gramlng of this permit.
P*1A a /I AIR HANDLING UNIT(OVER IfIpOO CFM)
t ilpolos.JnPr- S///iii
Signal roof ApphcenUGYnlnnr - IDeu EXHAUST-HOOD(W/DUCT) PAID
HAFARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt# p .../�
Will the vpdirmin or Boum building occupant wort or handle hazardous material HEATING UNI'1'(OVER100,00(d)BTU) TOTAL: ( ,k y
us defined by the Cupertino Municipal ucipal Code,Chapter 9.12,and the Health and Safety , 1 x
Cale,Semlon 25532(.)"/
C3 Yea 11 No VE.NTILA'RON 17AN(SINGLE RESID) S k_` .O6
BOILER-COMP(3HP OR 100000 IVI'U) ISSUANCE DATE 1I�_ry4
Wus air
applicant oants as defined
by the
nBay Amu Air Quality .nage emit n A
hazardous ah comvminonin m defined by Ne Bey Arev Air Quality Management BOILER-COMI'(OVLR 100,000 RTU) T� H
DistnctP
❑Yes ❑No NEW RESIDENTIAI.MECH. SQ.Ff.
1 have reed the hazardous materials requirements under Chapter 6.95 of the MAY 18 894
California Health&Safety Code,Sections 25505.25533 and 25534. I understand that
if the huilding does not currently have a tenant.that it is my responsibility to notify the
Oweupanl of the mg.hanros wHeh max,be at prior to mtemoa of a Certireale of 01 y QI- Wren I UvU
"ujat p
Owner or au0onsed agent Data TOTAL: ISSUED BY:
OFFICE