26839APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO Bim:DTNr:-E1'¢rntra?A'
APPLICATION/PERMIT 'I.DMBING-MBCHAN ICA I,
BUILDING DIVISION BUILDING PROIELT IDENI'IFICAI'ION
FRESH NO,
26839
BUILDING ADDRESS:
SANITARY NO,
APPLICATION SUBMTr1'AL UA' 117,
T
UNIT# LOT#✓���
—y y
OWN� 111145M PfiONF.:
SHO
CONTR=CTOR'SN P ,S I IC NO:
Ll/(N Ageo
N/C
CONTROLM
ARCHITEC'DNGINEER: LIC NO:
L AU RESS: !t ` /9 aa�
G'
CONTACT: PHONE:
�J''�/J
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
/J r/f (�
\t "G .JC _41a 15, -
BLDG ELECT PLUMB MUCH
❑ ❑ ❑
PERMIT ISSUANCE
ICENMi. CONTRACTOR'S DECLARATION
ya provisions p gwi
IMreb f um that l um licensed under fC?oter 9(commencin N
APPLIANCES -RESIDENTIAL
LOB DESCRIPTION
of Di Sof IM1e Business and Pmfessio en/d�mky licenu is in
fore
PANELS
/Code,
lull and
full farce and m
- 15 6 366
License Classes 36 Crooner
Data COnTS
UP TO 200 AMPS
-
- 11X10 AMPS
DECLARATION
I understand my plansRSM1WI be used az public recrds
OVER
OVER 1000 AMPS
n t I �1rL(I�1 )sftf-1 n e
—\ �I�`• �""1 tl tl��
$ISQ. fT.
SIGNS EECTRICA1.
I/
I1,—r�
111 E
Licensed Professional
OWNER-BUILDERIaDECLARATION
SPECIAL CIRCUR/MISC.
L t l
a law for the
I hertby affirm that I am commit from the Cosions
TEMP. METER OR POLE INST.
following Code:city or county
Professions Ca e: Any
Hmcaumnarfusinessand
which or reca
wbi,M1 myuima n permit m constrvet, akeq improve, demolish, or a ri mi any awnum
to islicensed0. smmmcm
ichCo
fiLLicense
POWER DEVICES
sof the tractoro
rsunttots provisions La
That he is ncing w pursuant m the provisions of the Convenors License Law (Chapter
that
9 (commencing 3 o the Code)
SWIMMING POOL ELECTRIC
VALUATION
that he in dam and the basis for the alleged esemrm to civil p aloe'" of
emiirn01100)he basis edexessvo.Any'kila
or Sectio he 131.5 by l ny applicant
doll fora permit subjects the applicvuo a civil peviry of
Section ]W LS iv any hundred
❑not ml, asownerofthepropenY.ormyemployeeswiN wage mN<irsolecompenseuon.
momreown rofthe roNaylarmyemp.
/ 00 ~_
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELECIR SQ. Flt
ST IES
'TYPE CONSTRUCTION
wi i l do the work. and the nmaure in.. imande i offered for sale (S.. 7044, Bushes
and Professions Code The Contractor's License Law does not apply to an owner of
propenywhobuild orimpmveadmiean,and whodoes such wmk Intonation through his
own employees, provided that such improvements are not intended proffered fornale. If,
OCC. GROUP
RES. UNITS
TOTAL:
however, the building or improvement is sold within one yearo esunpledon, the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sealed'
❑ 1, an prnpeny,amexdusively contracting with licensedconwcmrsm
QTY. PLUMBING PERMIT FEE
FLOODZONE
APN
onstmcl the project (Sec 70k4, Business and Profession, Carlo:) The Contractor's
Licenttlrwdmsnmapplytomownero(pmpenywhobuildsmimprovu Nemo.,end
PERMIT ISSUANCE 2
whoconwcts for such projects with a<ananclor(a) rcenscd pursuant tothc Commator'a
License Law.
ALTER - DRAIN & VENT - WATER (FA)
FEE SUMMARY
❑ 1 am exempt under Scc. , B & P C for this reason
BACK FLOW PROTECT. DEVICE
OUTSIDE 'ISE.
SANITARY YN
RECEIPT
Owner Dam
DRAINS- FLOOR. ROOF, AREA. COND.
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX YN
❑ Ihereby affirm that l have a certiEcam ofronment to self -insure, or a mnificateof
Workenc Compeasation Insurance or a cmifiei copy therwf(Sec. 38M. Lab C.) which
covers all employee's under Nis permu.
Fuji, #
MIXTURES - PER TRAPRECEIPTp
PARK FEE Y N
RECEIPT #
GAS - FA. SYSTEM-] INC. 4 OUTLETS
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHESCK FEE
❑ Certified copy is hereby famished.
GREASEIINDUSTRI. WASTE INTERCEPTOR
GRADING FEE
❑ Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKL•RS'
GREASE'1'RAP
SOILS HE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM IA. 200F1.
ENERGY FEE
(This malimnnced not becompined ifthe permit is intone hundred dollars(SIM)
or
WATER HEATER VOVENT/ELECTR
I certify that in the performance of lie work for which this pcmliIissued. Ishan
nal employ y on in any m er sV ay ie�.9 the Workers'
Gsapemm�onnl�nof Califnminte �6
PAID Date ReceiptM
WATER SYSI'EM/IREATING
Appli<e tii
NO'1'ICIi TO PLICA ':1Lafter making this Certificate of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. PT.
TO'PAL:
become su uolhe\ otters Compensetian provisiom of N<Labor Code, you most
funhwith amplywiNsuch provisions Or this permit shall be deemed revoked.
BUILDING FEE ZDV
SEISMIC FEF.
CONSTRUCTION LENDING AGENCY
I hereby affirm that hem is a construction lending agency for the performance of
Ne work for which Nis permit in issued(Sea. 2097, Civ, C.)
TOTAL
ELECTRIC FEE
Lender's Name
QTY. MECHANICAL PERMIT FEF;
PLUMBING ME iJ
Under', Address
1 acidly Nat I have read His application and ante that the above information is
men. Iagree to comply with all city and county oNinari and nate laws mlating to
PERMIT ISSUANCE
MECHANICAL. FEE
buildingcanxwnion, and hertby authone, rtprtunmtiva ofnhis city Intoner upon the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX b' Iva 0 a+
(We) all to save, indemnify and keep harmless the City of Cupertino against
ban tics,judg costs undexpen.sea which may in any way accrue against said City
AIR HANDLING UNIT (TO 10,000 CFM)
AUG 12 194
in conscquen the granting of Nis it. C
a
AIR HANDLING UNIT (OVER 10.000 CFM)
Signaw fApplicv0 sura nr Dam
EXHAUST HOOD (W/DUCT)PAID
��21,�".Uf rpl�NC IINV
'r
HEATING UNIT TO 1(10,0011 BTU)
7AZARDOUS MATERIALS DISCLOSURE
Date Reccyn0
HEATING UNIT (OVER I00.000 BIU)
TOTAL: f p
Will thea imam or future building occupvl snore or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
VENTILATION PAN (SINGLE RNSID)
Cade, Section 25512(a)'I
❑ Yes 1:1 No
T
BOILER - COMP(JHP OR 100.000 BLU)
Will Nee licnm orfumrthuilJin ecu Iusce tordevitts which emit
pp gn pun yuipmen
UU
BOILER- COMP (OVER 100,000 BTU)
hazardous air contaminants as defined by Ne Bay Area Air Quality Management
lDiaun
El yen ❑ No
Yes
L'
12 199,e
TI
NEW RESIDENTIAL MECH. SQ. FT.
1 have read the havadous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533 and 25534. I understand that
if the building does not curreally have in larva. that it is my responsibilitym notify the
cupant of the requirements which must be met prim no issuvee of a Certificate of
Occupancy.
G. INSPECTION DEPARTMENT
CITY OF CUPERTINO �S
ISSUEDRYjOe— pA./%J/Ld..CC.e•
BL
Owner or malmnmJ agent Dale
101 Al,
orrlct