26263 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO eQ°l°�G-�"- PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MTIDEWIFIC 26263
BUILDING PROJRC.T IDENTIFICATION
BUILDING
'ADDDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
/�/O � ' I tel/ WO+/�'J/ UNir# LOT#
OWNERS NAME: // �/a�$ /�.�.al PHONE: �c CONTRAM OR'SN LIC NO:
IO r SJatAA F,S�AR/�S(i10 Z§2-2/!!l N)V COYIKOLIt
RCHITECIENGINEER: LIC NO: ADDRESS: - ❑
CON'1'ACI': PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG F PLUMB MECH
PERMIT ISSUANCE ��-.
LICENSED CONTRndvrpmSDECfA1vPtw9 APPLIANCES-RESIDENTIAL JOB DESCRIPTION
OCZ Ihereby 700)(D ffnmthall am ofthe edonssand sof Chapter9(commencingwith
WW Sxtion]000)of Uivision3of the Business and Rvfessions Cody and mylicenu is in PANELS
FK Wf-. full force and effect.
FZW Licenu Clercs Lic.# UPT02MAMPS
y<vert Date Contractor 201-1000 AMPS SQ,FT.FLOOR AREA $/SQ.FT.
-z FOr — ARCHITECTS DECLARATION OVER 1000 AMPS
P"iW l understand my plans shall be used ns public records.
o z_a SIGNS ELECTRICAL
Qx5" Licensed Professional
C� OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
XO�U I hereby affirm Nat I am exempt from Na Ccuumcmr's License Low for the
VJ 3 V, following remon.(Section 703 1.5,Business and Professions Code:Any city or county TEMP.METER OR POLE MST.
1_-U C)l which requires a permit to construct,alter,improve,demolish,or repair any structure
d, prior to it issuance,also reyuites the applicant for such Permit rofleasigned smmmem POWER DEVICES
IyK�O Nat he is licensed pursuant to the provisions of the Contractor's Licenu Law(Chapter SWIMMING POOL ELECTRIC _+
e Xo� 9(cnmmencing with Seaton](100)of Division Jofthe Business and Professions Code) ^ VALUATIO/N� VQ
,_Z_ mction7dial he 3L5b exempt
anyapromamdthe rapermit
erisfonhectsthedexcmption.Any toacivlPenaltyof OUTLETS-SWITCHES-FIXTURES 33`11 V
5=Y a.,more
In L5byhundred
dollaror$500).tsubjens the epplicanuoecivil penalty of J
E-0 nor more than five hundred dollars($SWI. NEW RESIDENTIALELECIR _SQ.FT. STOkI' TYPE;CONS'11tUCf10N
X=ta ❑ 1,mowneroftheprop ay.ormyemployewwithwagesmtheirsolecompemadon.
q,;!2 will do the work,and the.structure is not intended or offered for safe(Sec.]094,Businus
and I'mfcssions Code:'ILc Comranor's License Law docs not apply to an owner of O -
property who builds or improves thereon,and who does such work himselfor through his
employees,providedrhatsuch impmvemen6arenorinrendedoroffertdforsale.If. C.(I Emu k TEN, I NKFS.VNIUs
however,the building or improvement is sold within one year ofcompletion,theowncr- b"it
builder will have the burden of proving Net he did not build m improve for purpose rf F1
vide) QTY. PLUMBING PERMIT Oo ZONE ARN
11
�,m owner ofthe pr c.70,,amencl es s ely semcontractingowng s C de)n mntrmmrx to I'� Z Z
Licenser w project(Sec.to
Business ora Professions Code:)The Convenor's YA E
License Law does not apply to an ownerofprnpenY whobuildxorimprovestherron,and PERMIT ISSUANCE
who contracts forsuch projects with acontracem(s)licensed purseam to Ne Contractor's ALTER-DRAIN&VENT-WATER(EA)
License Law, ( FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this mason OUTSIDE FEES
BACK FLOW PROTECT.DEVICE
SANITARY Y N
Owner Data pRAINS-FLOOR,ROOFAREACOND. RECEIPIp
WORKMAN COMPENSATION DECLARATION , , . SCHOOL TAX Y N
❑ Ihueby affirm thetlhave ecenilicae of ronsenvo self-insure,orncertificmwf FIXTURES-PER TRAP RECI?IPT#
Workers Compensation lnsuranttoracatified copy,themsef(Sca.3800,Lab CJ which PARK FEE Y N
lecrotrutill employee's under this permit GAS-EA.SYSTEM-1 INC.4 OUTLETS RE i1PTat
Polcy# B INGD ISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHEC
❑ Certified copy is hereby famished.
❑ Certified copy is fled with Nc city inspation division. GREASEI1NDUSTRI.WASTE INTERCEPT OR GRADING '. JT.TA1
CERTIFICATE OF EXEMPTION FROM WORKERS' GRF-ASETRAP SOILS COMPENSATION INSURANCE
(This seediomncal not becamleted ifNe permit is far one M1undmildolhrs($100) SEWER-SANITARY-STORM EA.200Ff. ENERG FEEless.)I certify that in Ne Fermarnance ofthe work for which Nis per mit is issued,Ishall WATER HEATER WNENTFLECIR
nor employ any person in any manner se,as m become subject to Ne Workers' PAID
CompenamiouLawsofCalifornia. Date - WATERSYSTEMiTREATING DateQz Applicant
z 0NOTICETO APPLICANT:IL after inking Nix Certifcam of Exemption,you should NEWRESIDENTALPCMB. SQ.FT.emptisforthwith comply with such provisions err this permit sbell he deemed rcvnked. BUILDING FIiIi CON$TRUCIION LENDING AGENCY SEISMIC FEE �a
z I hereby effort that there is a construction lending agency for the performance of T L 1 ELECTRIC FEE lJ
U O the work for which this pemtit is issued(Sec.309],Civ.C.)
Lender's Name PLUMBING FEE
u" F Lenders Address QTY. MECHANICAL.PERMIT FEE
U U I certify that I have read this application and stem But Ne above information is MECHANICAL FEE
croeut. I agree to comply with all city and county ordinances and some laws misting to PERMIT ISSUANCE R
F' building construction,and hereby authorise representatives ofthis city to enter upon the CONSTRUCHONTAX
Uz above mentioned property for impection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep hornless the City of Cupertino against
Iabilides,judgmems.costs and expenses which may in any wayaccruc against said City AIR HANDLING UNIT(TO 10,000 CFM)
in cn equence of the grandngof Has permit.
AIR HANDLING UNIT(OVER 110.000 CFM)
ignature of AppllcanUCommctor Use EXHAUST HOOD(WIDUC)
PAID
I IAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.0110 BTU) Date Receipt
Will the applicant or future building occupant store or handle haurdous materia
as defined by he Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IN."BTU)
Code,Scctiu i 255321a)1 VENTILATION PAN(SINGLE RISID)
❑Yes RN.
ISSUANCE DATE
Will Neapplicanmrfuncrebuildingoverpol use equipmemordeviceswhichemit BOILER-COMP OHP OR 100,000 BTU)
Nous air commitments as deri al by the Bay Amer Air Quality Management BOILER-COMP(OVER IN," p
risvicT, f p A 0
i ❑Yes IV No NEWRESIDENTIALMECII, SQ.FT.
I have read the hazardous materials requirements under Chapter 6.95 of the APR 2 0 1994
California Health&Safety Code,Sections 25505.25533 and 25534. 1 understrnd that
if the building does not c tmemly have a tenant,that it is my responsibility to ratify Ne
occupum ofthe requirements which must be met prior to issuance of s Certificate of
Occupancy. Ci11T�/
L ~ tr ,O
Owner m authorized agent Dole T AU ISSUED BY:
OFFICE