26316 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINOB 16UIS0-MAUFRICAL PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. _ f�L^ Q q Q
16 BUILDING DIVISION BUILDING PROJECT'HIEN"I FICAI]ON G U J
BUILDING//'ADDRESS: SANITARY NO. APPLICATIONSSUUBBMI`gTT/A`�LDAAATE
(rf cl— UNIT# LOT# _ l��( ` 1
0 ikS NAM P 0 E: CONTRA ISN E: CND. l
�` N/C CONTROL#
• ARCHITECT/ENGINEER: LIC NO: KESS: ❑
CON'EACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT F'EE
.BLDG F1O PLO II
B MEC
PERMIT ISSUANCE aF '
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ihercbyaff DMom 3 of flansedun,,.rovi onsions Coder and mmencise is in
'Woo W— Section 0000)of Divisiun 3 of Ole Business and Professions Code,and my license is in PANELS ��� �
¢,t full force and effecq_W Iwk 30 - UP 10200 AMPS
y6aDatct'sc Flrss C�Conimw ✓� 201.IM AMPS
F
ZOnz ARCHITECTS DECLARA 1 N OVER Ia10AMP5 h SQ.FE.FLOOR AREA $/SQ.FT.
1 understand my plans shall be used ni public records. Bp.� pp T
OZ—O — I E ® I N
F„y�; SIGNS ELECTRICAL
Q Y�,
Licensed Profcsxional _
a' �Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. t
X- aF` I hereby affirm that 1 am exempt from the Conuactors License law for the
m3ay following mission.(Section 9031.5,Business and Professions Code:Any city or county TEMP.METER OR POLEINST.
F ISS 4 which rcyuims a Permit to construct,alma,improve,demolish,or repair any structure
KWQ� to its issuance,also res the applicant for such un file.signedsttement POWER DEVICES
thaprier resmaterial the pP Permit Law
a
(al tY�W 9(c heisncing with Section
n700)of Provisions of the the Business
License Law(Chapter SWIMMING POOL ELECTRIC
aaort 9t that
he is exempt therefrom
Division the theeed exemptio Professions Code) VALUATION
tr• Seel Po 7031. b any applicant
romanf ra permit
subjects t dexem exemption. violation f
W=m F alleged pion yvioaiono OUTLf;TS-SWITCHES-FIXTURES
1..ZQ mmlone than
ha 7031.5 by anyapplicantforapermit auM1je<kx the applicant toacivil Penalty of
=SO not m1,cownfrvehondreddollarniyem). NEW RESIDENTIAL ELECTR _SQ.IT. STORIES TYPF.CONSTRUCION
M L ❑ base wrk.an Hestrcrty.ormyempindedorthwagamthe(See.comper¢adess
6'3=o will Pathework,CoI, strucmrcisnmintnndcese Law doesed not
Business
and Professions CtaJc:The Commcmr's Lirensc haw does nm apply to an owner of
property who builds or improves Iherenn,and who does such work himself or through his
1 provided that such improvements ' offered forsale.If,
OCC.GROUP RES.UNITS
own employees,pnrvi provementaaenotmtendedur
the
on.
he
huilder illhave the burden of erneatproving
issoldhe did
ot build or improve
purpose f TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sal.).
❑ I.asownerofthepmpeny.amexclueivelycnnoatingwiihlieensedcanvacmrsm QTY. PLUMBING PERMIT FEE FLOOD].ONE, APN
construct the project(See.9045,Business and Professions Cale:)The Contractors
License lawdceznot applytoanownttofpropcny who buildsm improvesthereom and PERMIT ISSUANCE
whocnnwms for such projects with acentractorts)licensed Frustum to the Contractors
Live Law. ALTER-DRAIN&VENT-WATER(FA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE OUTSIDE.FEES
SANITARY Y N
Owner Dae DRAINSFLOORROOF, GONDRECEIPT
, , , .
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y - N
)❑ Thereby affirm 0alhaveucenifcam ofconsenno self-inxure,oracmificme of FIX'T'URES-PERTRAP RECF.IPP#
Workers'Compensalion Insurance or a certified copy thereof(Sec.3600,Lab C.)which PARK FEE Y N
covers all employees under this permit. RECEIPT#
GAS EA.SVS'IEM-I INC..OUTLETS
Policy. BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK Flip
❑
Certified copy,,hereby fumishW.
Certified copy is filed withthe city irrvpection division. GREASE/INDUS'1'RL WASTE:INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSORGSETRAP- SOILS FEF.
COMPENSATION INSURANCE
Thi-etiianncednot IN,emi,pined Hire Penor is outrun.hundred dollars($100) SEWER-SANITARY-STORM EA.200FT, ENERGY FEE
or los.
I cenify that in the perfarnance.fibe work for which this permir is issued.(shall WAIT:R HEATER W/VENWELECTR
not employ any person in any Planner so as m become subject to the Workers' PAID
Compensation Luwxnf Califomia. DateWATER SYSTEM/BEATING Dae Reccipt#
Q Z Appllcanl
Z0 NOTICE:TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
f" to became subject to the Workers Compensation provisions of the labor Code.you most
> forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
0. Q CONSTRUCTION LENDING AGENCY SFISMICFEE
n Z 1 hereby affirm that there is a construction lending agency for the performance of TOTAL: ELECTRIC IEE
U O the work for whim this pe.it is towed(Site 3197.Civ.C.
Lenders Name
Lendcr'a Address QTY. MECIIANICAL PERMIT FEE PLUMBING FEE
U I certify that I have read this application and state that the above inlinmmion is MECHANICAL FEE
}' W curet. lagremcmnply with ell city andcauntyordina.ccs and state laws relaying to PERMIT ISSUANCE ��
building construction.and hereby authorize represermtives of this city to enter upon the
U above-mentioned property for inspection purposes. ALTERORADDTOMECH. CONSTRUCTION TAX
(We)agree m xavq indemnify and keep harmless the City of Cupertino against
habditiesJudgmemu,costs and expenses which may in any way acerae against said City AIR I IANDLING UNIT(TO 10.(X)0 CP M)
in conttyuence of the gaming of this pe t.
AIR HANDLING UNIT(OVER 10.000 CFM)
gtgnt ifRppLtnmt%
_y
[)am
'Dam I P.XIIAUST HOOD(W/DUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO W"BLU) Dae Receipt#
Will the applicant or future building«cup.store.,handle h se rdous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU)
Gave,Seetion 25532(u)1 VENTILATIONFAN(SINGLEkE51 D)
11 Yes ❑No
,ISSUM'1 {JAN'E;LIATE
Will thcapplicant orfumre building«cupantus equipmentordeviceswhichemit BOILER-COMP(3HP OR I(MhfgO RTU) �'
moodous air contaminants as ddned by the Bay Area Air Quality Management BOILER-COMP(OVER IW,0W BTU)
District, APR 2 7 1994
❑Yes ❑Na NEW RESIDENTIAL MECH. SQ.FT.
Cahn!have read the haverdou.s materials requirements under Chapter 6.95 of the CiIy
ifte building
ing dM1&Safety Codecurrently
have
to ant.that
it is and responsibility
,understand that Ur L(/f ttt l jlV''1
i ccupanilof the requirements
meets have a must
1st, lett o is my muance of a e notify the V
occupant of the rcyuircmems which must be me prior to issuance o(a Cenifcate of
Occupancy.
Owner or unforced ,at Dae ISSUED BY:
OFFICE