26837 �waaw t IV eiLL IN INFUHMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - - - PERMIT NO.
APPLICATION/PERMIT PLUMBING CTI IDENTICAL
FIC26837ATION
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION '
BUILDING ADDRESS:
I�/, ,/`�h� �p SANITARY NO. APPLICATION/SIBIMPTALDATE
V `•C I �1� I sJV`/ M1'p LOT#
OWNER NAME: M HONE: RAfTf 'S AME: T� : Noe CONTROLp
NI
RCHITECf/ENGINEER: LIC NO: RE/S\V9.1 \R 5'Vq Q. ElS. I
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERM FEE
BLD L PLUMB µ[:CH
PERMIT ISSUANCE I� G7L�J(.` _l��jl`/
LICENSED CONTRACTOR'S APPLIANCES-RESIDENTIAL JOB DESCRIPTION
p yoZ Ihere0).1'by nnision that I nmlicensedinss Said isiomnf Cheerer Said mmencise with'
00F Section]000)of Division 3 of She Business end Pmfessiam Code.end my license is in pANpyq
U no n
License
f 11 f MeCJanqJ off
a yVy or Licenu Conti UP TO 200 AMPS '✓" , l e\ W
y Q h Dam ConTS OVER
-1000 AMPS ✓✓✓✓�eee•VIII SII, �!!e SII, �/�/
Z~Oy�. ARCHITECTS DECLARATION OVER IOOOAMPS SQ.FT.FLOOR AREA S/SQ.FT.
0z ❑ I undcrsmnd my plans shall h used as public metritis.
FNSdyto.y.d.1 licensed Profcsssonel
SIGNS ELECTRICAL
�CAd OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
xa'O y U I hereby affirm Net I am exempt from the Con e.License law for the
0+13 O y following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE MST.
f" w which requires a permit to construct,alter,improve,demolish,or repair any structure
zg 7 Pummits iuuance,Jsorequiresthe applicantfmsuch pemdtmfdeesigned ssamment POWER DEVICES
.till Oa that he is licensed pursuant to the proviemisof the Contman's License Law(Chapter
d p 90commeneing with Section 7000).[Divisian 3af Ne Business and PmfeeSWIMMING POOL ELECTRIC sions Cade) VALUU
_y or Not he lseumpstherefrma and the busisfee theelleged exemption.Any Antennae OUTLETS-g WITCHES-FlXTURES
�. Q
Section by any applicant fare pennitsubjects theapplicant toe civil penaltyaf O
cri
C G not more than Eve hundred dollars(5500). NEW RESIDENTIAL ELECIR _SQ.PT.
❑ I,nsownerefthepmp ny,mmyemployeeswiNwagesutheiraolec=Nmauon, STORILS TYPE CONSTItUC ION
NO
will do the work,and lhesuu oo.is not intereolmoffend for see(See.7044,Business
and Professions Code:The Contmctols License law does not apply to an owner of
pmpen y who builds or improves thereon,and who does such work hi mse If m through bi s
ownemployees,provided that suchimprovemenmare not intendedmofferedforsale.If, OCC.GROUP RES.UNITS
however,the buildingor improvement is sold within one yearn(completion.the ownm-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,mownerofNepropeny,amexclusivelycrmrnctingwithlicenudconvectonm QT' PLUMBING PERMIT FEE ELOODZONE APN
constmet the project(Sea 7M4,Business and Professions Code')The Commeam's
License Law does not apply to an owner of property who builds orimprov.thereon,end PERMIT ISSUANCE
whocontmcnforsuch projects with a communs(s)licensed pursuant to the Contmctors ALTER (lacenselaw. i
❑ 1 am exempt under Sec. ,B at P C for this reason BACK FLOW PROTECT.DEVICE
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. ! za",
WORKMAN COMPENSATION DECLARATION Ihcreby effimm thatlhaveecenific¢ofcnmcmto selGinsur<,macenificomof FIXTURES-PER TRAPorkerv'Compensation Insurance or acenifed copy thence(5..3800,Lab C.)whichmovenallempmyersundcrthispermit. GAS-EA.SYSTEM-I INC.4OUTLETS M
Policy N BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECKFEE
[:1 Certified copy is hereby(umished.
❑ Certified Copy is filed with the city inspection division. GREASFANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(INS section need not be completed ifthe permit is fmnn,hundreddollan($IN) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or I.s.)
I certify that in the Performance of the work for which this Permit is issued.I shall WATER HEATER W/VENTICLECTR
not employ any person in my mummer so as to become subject to the Workcri PAID
7-r Camps xalm.Iawsof California. Date WATER SYSTEM/1'REYDNG Dote Receiptp
Applicant
Z0 NOTICE TO APPLICANT:If.ever me .&this Cenificateof ExmnInan,ya.should NEW RESIDENTIAL PLMB. SQ.ET. TOTAL:
p .r becomesubj.no the Worker's Compensation provisions ofthe Labor Code.you must
C4 > forthwith comply with such provisions or this pennitahall le deemed revoked. BUILDING FEE
aA CONSTRUCTION LENDING AOENCY SEISMIC FEE
z I hereby affirm Nm then Is a construction lending agency fm she Performance of
V O the wmk for which this pounds is issued(Sec.3097,Civ.C.) ELECTRIC FEE
Q ULeade.Name
Lender's Address QTY, MECHANICAL PERMIT FEE PLUMBING FEE
L2J I certify that 1 have mead this application and state that the above information is MECfiANICAI.FEE
y
—t—
correct. I game,to comply with all city and county ordinances and state lows relating to PERMIT ISSUANCE 7 building construction,and hemby authorise mpreuntativesofthiscity m enterupon the
V above-memione t property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)ag.c t.save,indemnify and keep harmless thef I{�0
lobiliti.,judgronss.costsandex enseewh'h meymanywa not. ily AIR HANDLING UNIT(TO 10,OIXI CPM)
sequence o the 1n tit . perm
AIR HANDLING UNIT(OVER I0,"CFM)
marc of Applican ' tncmr IM�No, ry- EXHAUST HOOD(W/DUC
PAID
HAZARDOUA RIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dune RuxiptN
Will the applicant or future hu occupmt Store or handle hamNous material IIEATING UNIT(OVER 100,0110 11711) TOTAL:
us defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)?
11 Yes 13 No VENTILATION PAN(SINGLE RFSID)
BOILER-COMP DHP OR 100,0X10 BTU) ISSUANCE DATE
Will theapplicrosorfware buildingaccupanmseequipmonmr devices which emit iy �f q
yr emo mi...is as defined by the Bay Ana Air Quality Management BOILER-COME(OVER IOSLWE BTU) /I.•G M
Cl Yea ❑No NEW RESIDENTIAL MF.CIL SQ.FT. /N�
1 have ream
d the hardous materiels requirements under Chapter 6.95 of the lr
California health&Safety Code,Sections 25505,25533 and 25534.1 understand 01 VVr .n/
it the building does not currently have a mount,that it is my responsibility,in notify the l
occupant of she requirements which most be mer prior to issuance of a CerdOcam of
Occupancy. T{�/ga
Owner to uthonred agent Dam TOT' : ISSUED BY�/Y r
OFFICE