26956 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOLi N's-E'.L R AL PERMITNO.
APPLICA'T'ION/PERMIT PLUMBING-MECHANICAL gT n C
BUILDING DIVISION BUILDING PROJRC'TADENTIFICATION G J J
BUILDING ADDRESS: SANI'IARYNO. APPLICATION SUBMITTAL DATH
3 , NIT# LOTH
AF'el PHONE: C
N/C CONTROL
ARCI I, tNGINEE 1: LICNO: ADDR S'
�
CONTACT: PHONE:
QTY. ELECTRIC PI?RMIT hliE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMITISSUANCI: ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ny.Z Iherebyaffirmthatl am lice sed underprovisionsofChapm (cntrtmencingwith
WOO Secion]000)of Division 3 of eusineas and Prnfes.i C c,and my license is in PANELS
ts:- 1F--.. fu11 force andel
'2u License Clan, a Lic.g UPT02MAMPS
m=y Date - Cmnruam 201-IBM AMPS S FT.FLOOR LOON AREA $/SQ.IT.
ZOvR'z ARCHITECTS DECLARATION OVER TBW AMPS Q
OZ--M lu n yplans shall paused avpublic records.
F" W a SIGNS ELECTRICAL
� Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
I hereby affirm that I tun exempt Baratta Contmctora License Law for the
tai Sam followingourom.(Section 9031.5,Business and Professions Code:Any ciB'a,.anty TEMP.METER OR PPLE I .
which requires.permit to construct,alter,improve,demolish,or repair any drucmre
prior to it.issuance,alsorequires Ne applicanrtormeh permiuo file.signedstmemem POWER DEVICES
�O that he is licensul pursnnot to the powkiomnlthe Contractor's License La '—pmr
9(com erring with Section 7000)of Division 3 ofthe Business and Professions Cade) SWIMMING PO I!LEC]'R^C VALUA]'ION
y ,may or that he isexempnherefr..and the basis for thealleged e.empd.,Any violmianof OUTLETS-SWITCHES-FI%TURFS
�46 Section 7031.5 by any applicant for a permit subjects the applicantto a civil penalty of
not more than five hundred dollar.($500). .
W m ClI,usownerofthepropeny,ofmyempioyeeswiNwagmustheirsolecomNnsation, NEW RESIDENTIAL P.LP.C'fN 3 QPI'. STORIES ]'YPH CONS]'RUCTION
a3— willdo the work,and the structure isnot intended oreffered hassle(Sec. Business
and Processions Cele The Contraror'a License Law docs not apply to an owner of
property who builds or improves thereon,end who does such work himself or through his
wnemployees,Inovidedthat such impow emenaare not intendedaroffered horde.If, I OCC.GROUP RES.UNI'1'S
however,the building or improvement is sold within one yearofcompletion,the owner. TOTAL:
builder will have the burden or proving that he did not build or improve for purpose of
sale.).
❑ I,asownerofthepropeny,amexclusivelycmuactingwithlicanmdcommctorsm QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
on.trur the project(Sea 9044,13admas end Professions Code)The Contractor's -
Licenselawdoesnot apply toonownerofpropenywho builds othe"oves doctor.and PERMIT ISSUANCE
who contracts forsuch projects with a contractors)licensed pursuattvo the Contractors
License Law. ALTER-DRAM&VENT-WATER(BID FEE SUMMARY
❑ 1 nm exennpt under Scc. ,B&P C for this reason BACK ROW PROTECT.DEVICE OU'l PTES
SANITARY Y
Owner Date RECF.IPI a
DRAINS-FLOOR,ROOF, GOND.
WORKMAN COMPENSATION DECLARATION SCHOOL]'A% YN
❑ Thereby affirm thelbnveacenibcme of rmunutself-insure,orecenificate of RECEIPI'k
Worken'Campensation lrnurnnce oro certified nay Netuif(Sx.3flW,L.b C.)whieh IIXTUNfS-PLR TRAP �, PARK FEE Y N
n allemployc2 niy GAS-EA.SYSTI!M-I INC.40UTLRfS RECEIPT It
PolicyM P1 BUILDING DIVISION FRES
Company GAS-EA.SYSTEM-OVER4 RIO PLANCHECK FEE
❑ C fie danpyisherebyfumiskil.
.ciified copy is filed with the city inspection division, GREASI3/INDUSTRI,WASE INTERCEPTOR GRADING FE H.
CERTIFICATEOFEAMM RKERSGREASETRAP SOILS
CMPENS%:TON IFRO PEE
Olds section need not be completed if cont is flume hundred d.11.hPW) SEWER-SANITARY-STORM EA.200FT. ENERGY FET!
at less.?
I certify that in the performance< he work for which this Nait is issued,^ 1 WATER IIFATER W/VENf/T:LECTR
not employ any person in any m ter so as Nn became su o the W r PAID
Compensationlawsof Colifard Date WATER SYSTEM[TREATING Data Receipt
Applicant
NOTICI!]'O AtPPI.ICAN'1': ficnakingthls Cenificaro x ptssgssqQQ��n,ymsha Id NEWRESIDLNTIALPLMB, SQ,FT. TOTAL:
VJ become subjecnotbe Wo 1_/___r'pensation provisio of a Lyldl)C�I.,.must
; foMwith comply with ch provisions or this pe deem���✓✓jj d. BUILDING FEE
P. (� NS'fNUC1'10 N AGV y/ SEISMICFEE
7 z Iherebyaffinnmm erentiems ruling ag c r the performance TOTAL: ELECTRIC FEE
V O the work for which this pe itis isued(S c. ],Civ.C.
Iznderx Namc '� ' PLUMBING FEI3
O f-- Lenders Address Q7`Y, a MSCI{ANICAI.PERMIT r{ FEE ' STO
V 1 certify that I have mad 's epp^icmion and store that Ne above mf utio s
erareet. logreooreomplywnha city anJ rnunty ordinances anA stoat le relmmg to PIiRMI]'ISSUANCI! MECHANICAL FEE
1"u y building construction,and hereby Ihorizerepresentativesofthischyt meruponthe CONSTRUCTION TAX
V Z aboveanentioned property for ins 'tion purpos a. ALTER OR ADD TO MECH.
(We)agree a save,indemnify utd keep hatedless the City a aped
against
liabilitiex,judgmcnts,coact andexpcns s whichnot,himyway. rueago uumie City AIR HANDLING UNIT(TO 10,000 CPM)
in conserpmaceof the granting of this it.
AIR HANDLING UNIT(OVER 10.000 CFM)
Signature of Applicaot/Contractor Dom EXHAUSTHOOD(W/DUC'1
PAID {p��
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I ,WO BTU) 4 Rmcip.
Will the applicant not future building occupant store or handle bmarmas mumrial
u defined by the Cupertino Municipal Code,Chapter 9.12,soothe Health and Safety IMATING UNIT( LR IN),"BTU)
Cade,Section 2553200)
11 Yes 11 No Vf?NTILA O WN(SINOLP.RESIIp
ISSpc pct
Will thea licant or future buildin eu tux tordeviceswbich emit BOILER- MP(3HP OR 100,000 BTU) I-' k'f1
PP Bot' pan equipmrn
hazardous air conmminams as defined by it,.Bay Ates Air Quality ManagementN
BOILER-COMP(OVER 104,000 BTU) C��
DisairY
ClYes C1No NEW RESIDENTIAL MECH. SQ.FT. MAR Tar n/ '1 0 1995
1 Love read the hazardous materials reyuiremems under Chapter 6.95 of the /�
Ce4� thXied4ent
ale Cody scetions 2s511s,25531 arta 25534.Ivnderstnnd Ont VIII Ur \zurel'{ o
iftt en llyiw¢cetermnt that it is my msponsibility to notify the
a Ileb n,nth�etprior tot iesrege0f a Cc iflcamoOwDom TOTAL: ISSUED BY:
OFFICE