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26226 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPEBUILDING.h. RIA PERMIT No. BUILDING DIVISION APPLICATION/PERMIT PLUMIIING-MECHANICAL BUILUING PRWEr-'1'IDENTIFICATION 26226 BUILDING ADORF.SS: SANITARY NO. APPLICATIONSUBMITTALDATE UNIT# IATA ER AME: �PPkHO'N'E: fOR'S NAME: eq ryyNIC CONTROL# •ARC ITIiCf/ENGIBEER: LIC NO: p X66 3 SS 9su CONTACT: ©R- PHONE: QTY, ELECTRIC PERMIT FEE BUILDING PERMIT INFO ELECT PLUMB MECH PERMIT ISSUANCE LICENSED CONTRACTOR'S DECLARATION OOZ , afPomtl em thaliceaudundproviainns ofChepner9( er APPLIANCES-RESIpENT1AL �� DESCR commencing with [W00 Seen,,. n]1100)OfIfUivision3 ufthe Rosiness end Professions Code,and mylicense is in PANELS KU6 full force and eRut. 'I I ZW 1.icenu Clev t Lic,p `/g I UP TO 200AMPS Contractor. ,Oz ARCHITECTS DECLARATION 2111-I(N10 AMPS ZOm— OVER IOW AMPS ```^^^...pFFsss,,...,¢¢¢OOR R E/SQ,FT. oz-0 I understwd my glens shell be used as Public racards. t A Q aLicensed Prnfusmnal _ SIGNS ELECTRICAL 1 I� 9 6Y OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. t ( J UTE R xOaU I hereby shorn that 1 nm exempt from the Conoacon"License Lew far the W 301 following mason,(Section 7031.5,Businca,mil Pmfessions Code:Any city orcounty TEMP.METER OR POLE INST. 7�y which requires o permit m constrvet,alter,improve,demolish,or roped,any structure fy L�>f prior to iO iswance,0150 requites the apPlicmt(in such Permit file o signed statement POWER DEVICES ty�.10 that he is licensed pursuant o the provisions of the Contractor's License Law(Chapter LxpO, round he is ixemwith eneion7UN)of e Division 3.fCa Business and AnyviolsCode) SWIMMING POOL ELECTRIC LUA]'IPA W—sn 9(caheisexempuhection7 end the Davie for he tte lett Business and.pnyvidotion ofde) (Z'_`--- Za Section 7031.5 by any applicant foPermit r a peit subjects then epplicanoo civil penalty of OUTLETS-SWITCHES-FIXTURES t m more than five hundred Jolles($500). ❑ I,asownuofthepmpny,ormyemplo«swiwNEWIDENTIALELEIR _SQ. T.m ageeaerwleomprLation, STORIES TYPP.CONSTRUCTION a3will do the work,and the stmchme isnot intended orofferM foraale(Sm.70,14,Business and Professions C.I.:The Convaanr's License Law does not apply m an owner of Property whobuildsorimproves duamon,and whod0es such workhimulforthrough his ownempleyeu,providedthawchimphoo.ms Oranmintendcd Orofferedforele.If. OCC.GROUP RFS.UNITS however,the buildingor improvement is sold within one year of completion,the owner- hander will have the burden of proving that he did not build or improve for purpose of TOTAL: sale.). ❑ 1,mown«ofthepmN"Y,ameaclusivelycon"ctingwiNlicenudcontractorsm QTY. PLUMBING PERMIT FEE FLOOD ZONE "N consumer the project(Sec.7044,Business and Profusions Carl The Cinamise.e. License Luwdoea not apply to un ownerofpropeny whobuilds orideproves therein,mit PERMIT ISSUANCE who conmrns broach preiects with ace ntecmr(s)licensed pursuant to the Connectors License Law. ALTER-DRAIN&VENT.WATER(FA) FEE SUMMARY ❑ 1 am exempt under Sec. ,B&P C for this,amort BACK FLOW PROTECT.DEVICE OUTSIDE Owner Data SANITARY YN_ WORKMAN COMPENSATION DECLARATION DRAINS-FLUOR,ROOF,AREA,COND. RECEIPT# ❑ l hereby affirm that l have a cenificete oferamem m self-iawrc.ora mNfcam f SCHOOLTAX y_N_ Wmkm'Com FIXTURES-PER TRAP RECEIPT'# pcyams nher this emn ttnified wpy thertof(Su.38W,lab CJ which PARK FEE Y N_ covers all employee's under this permit. RECEIPT# Policy# GAS-EA.SYSTEM-]INC.4 OUTLETS Company BUILDING DIVISION EELS ❑ Cenificd copy is hereby rumished. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE ❑ Certified copy is riled with the city inap«tion division. GRWEnNDUSTRL WASTE INTERCEPTOR GRADING FEE CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP COMPENSATION INSURANCE SOILS FEE (This voodoo near tan he complaeJ if the permin is for onehundrW dollars(EI W) SEWER-SANITARY-STORMEA.IWFT. orleENERGY FEE ss.) I canifyran in the pedmmeacanf Ne work for which Nis permit is issued.Loch WATER HEATER W/VENT/ELECTR not employ y son i any manner so as yy be subjagtt,q the Workers' PAID ma o Ca 0mie. Data Y `I � WATER SYSTRIATREATING O It net Date R«cipi# NOTICET P ICANT:If.after making this Certificate of Escmpnion,yintiould NEW RESIDENTIAL PLMB. SQ.FT. TOTA In becomesu a no the Worker's Compensation previsions N the Labor Code.you mush > fanhwith c ply with such provisions or this pent shall be deemed revoked. BUILDING FEE "a" LLI A CONSTRUCTION LENDING AGENCY SEISMIC FEE z 1 hereby affirm than Nem is a construction lending agency for the peffonneace of V O the work for which this pcmtit is issuW(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE Lks I.enders Name O Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE I certify that I have rand Nis application sod sate that the above information is L1s correctl agree to comply with all city and county ordinances and state laws relatingro PERMIT ISSUANCE MECIIANICALFF.E fn buildingemstruction,and hereby anthorim representatives afthis city to enter upon the V Z above-mentioned property far inspection purposes. ALTER OR ADD TO MECH, CONSTRUCTION TAX Iliad )agree no save,indemnify and keep harmlus the City of Cupertino against ju menta,cost nd oapenses which may in arty way«crumgainst sail City AIR fIAND1.ING UNIT(TO 10,000 CFM7 n gef this it. ^I9y AIR HANDLING UNIT(OVER 10.000 CFM) ufA onnuvmr Date EXHAUST HOOD(W/DUCqPAID HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100700 BTU) Daethe applicant or furore building occupant store or handle hazardous material by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,01M BTU) OT Code,Section 25532(q? 11Yea ❑No VENTILATION FAN(SINGLE RESID) Will n-it a lcentarfunuruburoad by penmu Ars.Rent Quality uanage ten BOILER-COMP QHP OR 100,000 BTU) ISSUANCE DATE •Lif� hazardous air comvminanta m dcfnN by the Bay Ame Air Quality Maegcmcm BOILER- COMP(OVER 100.00D BTU) ❑Yes ❑No NEW RESIDENTIAL.MECH. SQ.FT. e read the haurdom maeoals requimments under Chapter 6.95 of the 8 ealth&Safety C(de,Sections 25505,25533 end 25534. 1 understand then ing Jas not cummtly have-general.the it is my esponsibility to notify theApRf the requirements which must be men poor no issuance ofn Cenifcam of.mhonznd agent Data TOTAL: ISSUED BY: OFFICE