26347 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO .1IILIIINf:-RI.1'CTR1CA. PERMIT NO.
APPLICATION/PERMIT PLUMBING-MN:CHANICAL n Cg O A
BUILDING DIVISION BUILDING PROJRCTIDRN'I'I FICA TION L v J 4
❑WILDING ADDRESS: 7� SANITARY NO. APPLICATION SUBMITTAL DATE
UNIT# LOT#
O Its NA E. 111 k" PHONE: CON
A 'fRACI'OR'S NAME: LIC NO:
c--z_ -`�r�� fY� _SSL N/C CONTROLp
RCIIIT'BCT/ENGINEER: LIC O: ADDRESS: �W-�-� ❑
OLyC> 4 uvrqc DP-5l
.ONTACf: PHONE: a BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT PEC LDG ELECT PLUMB MECH
�L IDC/
PERMIT LICENSED tatIa CONTRACTOR'S
nsed un Cf OR'SDECLARATION APPLIANCES-RESIDENTIAL OB DESCRIPTION
p00 Ihcrebyeffumision 3 ofthvcdinss and rofesio@eode.and
my limew wish
u100 Section 70fXB of Division 3 of the Business and Professions Code,end my lacrnse is in ppryPJS
FdEtyFy-� full force and effect. • 1 w
Urease Class Lic.# UP TO 200AMP5 _
rn 6 y Date Contract 201-1000 AMPS
Z FO v0fei 7..1 ARCHITECTS DECLARATION OVER IO011AMP5 SQ.Fr',FLOOR AREA $/SQ.IT.
O Z—p 1 undersmnd my plans shall he used as public records.
F-rn t Irl SIGNS ELECTRICAL
Q �"3 Licensed l'rofesxional
La
"' EU
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
S�Od1- I hereby from but 1 em exempt from the Communes Lice.Lew for the
W 3 LL y following reason.(Section 7031.5,Business and Pmfeasions Code:Any city or county TEMP.METER OR POLE MST.
which requ ins a permit to cenolrvct,alter,improve,donard.h,or repair any immune
$!!}� prior to its issuance,also mquires me applicant for such permi0o rile a signed retirement POWER DEVICES
tC < Is
O that he is licomed pursuant m me psovisiom of the Contractor's License Law(Chapter
0.a 9(commcncin with Section 7000 fDivisian3ofthe Business and Professlom Code SWIMMING POOL EL C ^
Hoo
Bwi )n ) As W VALUATION
W=y onhm h7031.5 by N Fificaefroon f the basis for the alleged cxcmptiw Any violation of OIITLEfS S
F-Za Section TOl LS by any epplicentfon permit suM1jaB the applicentmecivil pevlty of
t marc run f vu hundred Jnllars($500).
C we ❑ LaowneroDheproruclumrmyemploycawiNwedforatheirsm.7044pemation, NEW RESID LECTRwit Q.FT. STORIES' TYPIs GQN$TRGCTIDN
do
W 3— and Protestant and e: o Cont s nor's License
nsero w dries not apply to
owner
is
of
and Professions Code:The Contractor's License Law does not apply m an owner of
pmpertywhobuildsorimpmvesthemon,andwhod ssuchworkhinuelfortroughhis OCC.GROUP RFS.UNITS
wnemploytts,pmvidcd that such impmvernentsartnm intmdedoroffertd(mule.If,
however.the building ormarovement is sold within one yemofcompletion,meawner
builder will have the burden of proving that he did not build or improve for puryou of
rv1e')' QTY. PLUMBING PERMIT FEE ROODZO APN
❑ 1,asawmr jeth(Sec.7 .Business
andcontractingProfessions
with licensed Conti contractors to
I.iceconstruct the project(Sec.oro Business and Professions Codep The Contractors PERMITISSUANCE
w cove Lewduranot apply masownerof p tunes)who se iIds m improve Commit end
whocomracu for projects wiNeconvennds)licensed pursuanOo the Conoumr's AAl.IER-DRAIN&VENT-
Licensu Lew. WATER(EA) FITSUMMARY
❑ 1 em exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE SANITARY OUTSIDE DEES
N
Owner Date DRAINS-FLOOR.ROOF,AREA,COND. RFCFIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ ]hereby affirm matlhave attrtificam of conunno self-inaum,an ttnifieam of CP p
FIXTURES-PER TRAP
/Werk1 hmbypevmionlmumnttoriccami ofcosomercof(Secum,or Lab CJwhich PA F1: Y N
covers ell employee's vndenhis permit
policy 11 GAS-EA.SYSTEM-1 INC.4 OUTLETS
DIV 'ION fL'FS
Com y GAS-EA.SYSTEM-OVER 4IRA) PIA CI
tinned copy is hereby famished.
Sided copy is filed with the city impection division. GREASERNOUSTRL WASTE INTERCEPTOR GRADING .E
CERTIFICATE OF EXEMPTION FROM WORKERS' OR BASE TRAP SOILS FEE
COMPENSATION INSURANCE r
nes section need not be completed Rare Permit is toren hundred dollars($100) SEWER-SANITARY-STORM HA.200FT. ENERGYsC
or las.)
I certify that in Ne performance of the work for which Nis permit is board,l shall WATER HEATER W/VENT/YLECTR
not employ any porus in any maser m an to become subject to the Workers' PAI
Compensmion Lassof Celifomia. Dam WATERSYSTEM/IREATING Date Receipt#
0 z Applicant
O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT,
TOTAL.
In becomexubjmt to the Worker's Compensation provisions of the Labor Code,you most
moi ; forthwith comply with such provisions or this permit shall be decreed revoked. BUILDING FEE t#
Z
CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby of art that there is a construction lending agency for me performance of
U O Ne work for which this permit is issued(Sec.3097,Civ.C.) ELECTRIC FEE
Lender's Name
F lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING F E
CJ I certify Net 1 have and Wee application and Nle Nat me above information is
LU rorrect.l agree to comply with all city and county oninences and stace laws relating to PERMIT ISSUANCE MECHANIC FEE
' building cmauumion,and hereby stillborn mpresarral admit city to enter upon the CONSTRUCT ON TAX
L) z nMve-mentioned property tion purpmee. LTER OR ADD TO MECH. �'
(We)egret tbton, t
and kaph
hmas the Cary of Cupertino againat
lie bilitiea.judgmemeswhich mayinuny way accrue against said City AI0.HANDLING UNIT(1010,fN10 CFM)
co y n pornmt.
AIR HANDLING UNIT(OVER 10,000 CFM)
nature cyAF, n can Dale EXHAUST HOOD AV/DUCI')
PAID
11 RDOUS MATERIALS DISCLOSURE HEATING UNIT CTO IO(LIIUB BTU) Dam Receipt It
Will the applicant or future building occiax m smrc or handle hamrdous n ateraal
as defined by the Clpcnino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER iW."BTU) L
Gale,Section 11Yce ❑Na 25532(x)7 VENTILATION PAN(SINGLB RESID)
❑
BOILER-COMP(3FlPOR IOB,ap BTU) ISSN„ EDATE
Willtheapplicam orfmurtbuildingmcupnm uuequipmenmrdevittawhich ersdt /s QID
homrdous air contaminants its defined by the Boy Area Air Quality Management BOILER-COMP(OVER IOgWO RTU)
Di,trint7 r�AY
11C319199
Yea No NEW R1351DENTIAL Mf:CH. SQ.FT.
1 have read the hazardous materials.requirements under Chapter&95 of the CIT./1 a`
CalifomielleulN&Safely CMe,S tium25505,25533md25534.lundersandmet sl Vf t,
if the building does not cumently have a mvnt,that it is my responsihility m notify me `Lr�s T/
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy. IVP
Owner maomm,edagent Dole A ISSUED BY: