26474 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
ITY OFCUPERTINO B ILIH G-KL, TR A PCRMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 26474
BUILDING PROJECT IDENTIFICATION
DING ADDRESS: 1 ('' / SANITARY NO. APPLICATION SUBMITTAL DATE
Q q (� AV`J O AV\— UNIT is LOT#
WN17RSNAMIE PI ONE: CONTRACTOR'S NAME: LIC NO: . N� IVVYff CONTROLp
I M l alc�.Z 'Z.
RCHI'IECT/ENGINEER: LIC NO: ADDRESS: ❑
k0id M f4j&w 1-"L 0 23
ONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEF.
O)BIAL i L ELE PLUMB M[CIi
PERMIT ISSUANCE ❑ 11
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL pR5/11yx1'I)N
Qwz I hereby affrmthal l Am licensed underprovisionsofLTaprer9(commencing with `7�1/`-+
X00 Section]000)ofDivision3ofthe ButinessandProfession.,Code,And my[it..isI. PANELS
tt� full force and effect.
Qz License Clara Lie.# UP T0200 AMPS
yGa Date Comracmr 201.1000 AMPS
,z8yZ ARCHITECTS DEC ARATION OVER I"AMPS 3.Q T�FLUOR AREA S/SQ.FT.
Oz—a l undermand my plans shall be used as public moods. �ar.r
P'4 t ai SIGNS ELECTRICAL f�
Licensed Professional 6�
6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. [��f ■ #
M°�OyF 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
t;3 LL to following mason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which requies a permit m constme%alter.improve,demolish,m repair any mmeture ^ E
��a. Priorto its issuance,Also requires the applicant for such Permit file A signed moment
POWER DEVICES PA
E'00 th.t he is licensed puts.......he prows..of the Cmarr ichor a License Law(Chapter
9(commcncing with Section 9000)of Division 3 ofthe Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATI _
yl_so orthm he isex,mptthercfmm And the basis for the alleged exemption.Any violation of O11T1.ET5-SWITCHPS-FIXTURES
tz< Sectian7031.5 byany Applicant fora pmain subjects the.pplicunt in.civil penAty of
Y not more than Eve hundred dollen($500). NEW RPSIDENTIAL ELECTR S .Er❑ LusownernflheprnpenY.nrmycmployaawith wagesutheirwlecompcmetion, Q STORIES 'TYPE CONSTRUCTION
y will doahc work,And the saactum isnolimendelmoffered Austria(See.7044,Business
and Professions Care:The Contractors License Law does not apply to An owner of
property who builds or improves thereon,and who does such work himselfor through his OCC.GROUP RES.UNITS
ownemployms,pmvided Natsuchimpmvem arenotinlendMorofferedfmsale.If,
however,the building m improvement is sold within one year of completion.the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
ie')' QTY, PLUMBING PERMIT FEE
C] I,asowncrofthepmp ny.amexclusivelyconuactingwiNlicensedcontnctonta FLOOD_ZONE APN
-
nsmictlthe prejat(Sec.7044,Business and Professions Cade:)The Contractor's PERMIT ISSUANCE
Licarse Lawdoesnot apply leanownerofpropenmv
y who builds.,impea thereon,and
whocontmets for such pmjals with acontracmgs)licensed pursuanno the Contractor's
LAL9'ER-DRAIN&VENT-WATER(EA) FEE SUMMARY
ice
❑nmLow.l am exempt under Sec. ,B&P C for this mason BACK FLOW PROTECT.DEVICEOff I SIDE P
SANITARY Y N
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF.AREA.COND. SCHOOLTAX Y_N
❑ Thereby efOnn Ontlhnveattttificete of cotuennoeelf-insure,araccrtifiwte of FIXTURES-PERTRAP RF.CF.IPf#
Wnrkere'Compensmion lnsuranttmvcmifiedcopy thereof(Sec.3B00,Leb CJwhich PARK FliE Y
rs el employee's under Nis permit GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISIOILIDES
Campany GAS-EA.SYSTEM-OVER 4 HA) PLANCHECK FEE
❑ Certifedenpyisherebyfumiahed.
❑ Certified copy is filed with Oso city inspation division. GREASF/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not bec.mpleted ifthe permit is forms,hundred dollars(S100) SEWER-SANITARY-STORM PA.200F1'. ENERGY HE
or less.)
I cMify that in the performance of the work for which this permit is issued.I shill WATER HEATER W/VENT/ELECfR
not employ any person in any magma so As to become subject to the Workers' PAID
Cnmpemmion Laws of C.ifomia. Data WATERSYSTId VrRE,VHNG a Receiptp
z7" Applicant
NO HCH TO APPLICANT:If,Are,..kingthiA Certificate of Haemption,you should NEW RESIDENTIAL PLMIL SQ,FT. TOTAL:
� In becomesobjano the Workefa Compensation provisions of the Labor Cade,you must
> forthwith comply with such Provisions.,,his permi,shut[be damst revoked. BUILDP1&kEArS95
L2I Q CONSTRUCTION LENDING AGENCY SEISMIC
I hereby affirm that there is a construction leading Agency for the performance of
U O TOTAL: ELECTRICS I�
Ore work for which thin permit is issued(Sec.309],Civ.CJ
Fs-.- Lendals Name Lcndcr.Address QTY. MECEFE
IANICAL PERMIT E PLUMBI(G FEE
OU
U I certify that I have Rad this application and she that the above Information Is MECHANI L FF.E
>sLtI correct.Iugra mcomply with all city and county odinencen and state laws reletingm PERMIT ISSUANCE
I^ building cmenuctioa And hereby Aulhmieem,amostivesofibis city to ems,upon the CONSTRU NTA%
U Z above-mentioned Wormy for inspection purposes. ALTERORADDTOMECH.
OVA)agree to save,indemnify And keep harmless the City of Cupertino against
liabilities,judgment,costs And expenses which may in Any way accrue against mid City AIR HANDLING UNIT(TO 10,000 CFM)
in eonsequcnca of the granting of this permit.
AIR HANDLING UNIT(OVIiR 10,000 CFM)
EXHAUST HOOD(W/DUCq
Signature of ApplicunVContrectm Date PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dune Receipt#
Will the applicant or future building occupant store or handle hamrdous material
as defined by the Cupertino Municipal Code,Chaplet 9.12,and the I lea th and Safety HEATING UNIT(OVER 100,0010 BTU)
Cede.Section 25532(A)T VENTILATION FAN(SINGLE RESID)
❑Yes %N. ISSUA DATE
Will theapplicanmrfuturebuildingoccupam useequipmemorchvices which emit BOILER-COMP(311P OR 100.1100 BTU)
hamrdom Air contaminants As defined by the Buy Area Air Quality Management BOILER-COMP(OV ER 100,000 BTU)
District? AN.❑Yea NEW RESIDENTIAL MECH. SQ.FT.
I have reed the haamdoos materials requirements under Chapter 6.95 of the /
Califomia Health&Safety Cole.Sections 25505.25533 and 25534. I understand that
if the bulldin cml have a tenant that it is my respomibility m notify the O
1 menti mer paler to i.amaae of A Ccrtifcmc.f 4
Ocu Wn Aare /•`Ur
O ramborimri rat rate TOTAL: ISSUED BY:
OFFICE