26132 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
W'OWA�:
PERTINO II 1 UI .-ELF. TRI AL PERMIT NO.
DIVISION APPLICATION/PERMIT PLUMBING.CTIDFANIFIC 26132
INIhUINC PROJECT IUMNT'IFICAT'lON
NOSS: (,-� SANITARY NO. 11--1
APPPLICATIONSUUBBMfITALDATE
C w UNITY LOT# GLr
PHONE: CON TOR'S NAM J �I /� -1AC NO: 1•
! NIC CONFIROLp
NEER: LIC NO'. ADDRESS: ❑
PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MF,CH
PERMIT ISSUANCE 00
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESID[NTIAL JOB DESCRIPTION
p u�z I hereby affirm that l am licensed underpmviaions of Chapter9(commencing with
FW OWO RaWhitfordndi
ce aDivis Division the Business and Professions Code,end my is in PANELS
fail 1 1
Licrnm Clur Lic.p UP TO TOO AMPS ` #
m<L Data Commit. 201-HNP AMPS
0.Z ARCHITECTS NDECIARATION _ �SQ.Pf.Fl.I� --y f/SQ.Ff.
2Om`- 1unJeraen0 my plans shall Das public ATIO OVER IOOO AMPS
P"�W SIGNS ELECTRICAL Loa
hS� Licensed Professional
N OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
q�(O iU 1 hereby afro that I ER exempt from the CRATIO/F License Law for the �s
W301 following mason(Section]031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST. � /.
C��� which rcquims a permit m construct.alm,improve,demolish,m repair any suactme POWER DEVICES
�t�i Y� priunoib issuance,almrequires the epplicam fmrsuch permitmfleasigned sm¢mem
L'a O Rat he is licensed puk...I to Ne provisions of the Conte ..e.License Law(Chapter
ai0P' 9 eommenein )of Division 3 of the f3mmessrnd Pmfessimns Code) SWTMMINGPOOLELECTRIC
x ( emit therefrom mad VALUATION
WKm mction7doa he 31.5b mayap therefrom a buis6nM1ects thedexempti to civiny l
of OUTLETS-SWITCHES-FIXTURES
Y Section ....by any opplicamforapermit subjects the applicant mecivil penally of
G wt more than five hundred dollars($500).
❑ Leaawnnofthepropcny,ormyemployemewlNwages.s Nei...lecmmpensmion, NEW RESIDENTIAL ELECfR _SQ.FT. STORIES TYPE CONSTRUCTION
d3_ will dathework,and thesuucmmisnm intended urofTered forsale(Sec.?UJ4,Business
and Professions Code:The Contractor's License Law does nm apply w an owns of
pmpenywhobuildsorimproves thereon,andwhoduassuchwork himselfortivough his OCC.GROUP RES.UNITS
own mmpl oyecs,pmvitled that such i mprmvemenU arc not ime nded or offered for mile.If.
however,the building mimprovement is sold within oncycar of completion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
\ ea10')' QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ I,uownerufthepmo ay,amexclusivelycontmaingwiNlicensedcontmmorsm
construct the project(Sec.70J4,Business and Professions Cade))The Communes
License Lawdoes not apply m.nowncrofprmpeny who builds or improves therman,and PERMIT ISSUANCE
.Who contracts for such projects whhacoatruutomm licensed pursuant to the Contractor's ALTLR-DRAIN&VENT-WATT:R(PA) FEESUMMARY
LiFc�iuc Law.
❑ m exempt under Sec. ,B&P C for this moan BACK FLOW PROTECT.DEVICE - O . DE
rM
SANITARY Y N
Owner -Dam- DRAINS-FLOOR,ROOF,AREA,CONE. RECEIPI'p
WORKMAN COMPP.NSATION DECLARATION SCHOOL TAX YN
❑ Thereby affirm thetl haveacenifiate of consenno xl6insum,mecenificme of TRAP RECEIPI'p
FIXTURES-PER
PARK REE Y
mken'Compemaion Insurance or a certified copy Neteof(Sec.390QIi6CJ which N
' ECEIPT#
rall employee,umler this perm). GAS INC.INC40UTLFTS
BUILDING DIVISION FEES
Policy Y
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is herebyahW.
❑ Certified copy is fwith th
led with the city inspection division. GREASEIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This,ecimn reWnot becompleted ifthe permit is forms,hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the performance m the work for which this permit is issued,[,hall WATER HEATER W/VENT/ELECTR
not employ any parson in any manner an a to became subject m the Workers PAID
Compcnamionl,awsof Coliform.. Data WATER SYSTEM[MEATING Dae RraF,#
O z Applicant
z 0 NOI'ICF.TO APPLICANT:If,efmr making this Canniest,of Exemption,you should NEW RES]0PIAL PLMB. SQ.FT. TOTAL:
rte. became subject to the Worker'a mCompensation provisions of the Labor Code,you must BUILDING PEE
7 forthwith comply wi ih such Provisions or this permit shall be deemed revoked,
CONSTRUCTION LENDING AGENCY SEISMIC ME
I hereby affirm that them is a com uctioa N
lending agency for e sa fa mantt of
U O T ELECTRIC RE
the work for which this per is issued(Sec.3097,Civ,C.) 6 to
Irnders Name PLUMBING FEE
0 F Lenders Address QTY. - .MECHANICAL PERMIT FEE
V I certify that I have read this application and sum that the above informniion is MECHANICAL FEE
r1`' I2a commit. Iagree to comply with all city and county orcdinaaces and state laws minting to PERMIT ISSUANCE
t-- building construction.and M1ercby nalloriurtprtsmwtivea of Niscitymrnmrupon theLI) CONSTRUCIONTAX
U Z alrove-mentioned property for inspection purposes. ALTER OR ADD TO MECII.
(We)agree w save,indemnify and keep hamdess the City of Cupertino against
liabilities,judgments,costs and expenses which may in my wayeccme sag Inst dCity AIR HANDLING UNIT(TO 10,"CFM)
cmnsequen o a granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
gig um of X,lievarjCmummor DM EXHAUST HOOD MMUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 1110,000 BTU) Dae Receipt Y
Will the applicant in future building occupied store or handle haardoua material OT L.
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,00 BTU)
Code,Section 5532(id?Year El No VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
Will theapplicant orfuturebuildingoccupant uxequipmenrmdevices whichemit
BOILER-COMP(3HP OR 10,000 BTU)
umoRm,eir conwnireams as defined by the Bay Arca Air Quality Marea,them BOILER-COMP(OVER 100,000 BTU)
District?
i ❑Yea 0 N NEW RESIDENTIAI:MECH. SQ.FT. PAID
1 have renIncautious the materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534. I understand Nat
if the building Joesnot currcndy hnveutenent,that it is my resp...Rilitywnmifythe MAR 11 X994
ottme
upam of the requirements which must be t prim to issuance of a Cenifiam of
Occupancy. Cu y
OwneroromhoriaeJ.,cut Data TOTAL: ISSUED BYur .L
OFFICE