26934 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING-LLE rRI AL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT
PLUMBINGROJECTRCHANIFIC 26934
BUILDING PROJECT IDENTIPICA'1'IOF
B ILDING ADDRESS: SANITARY NO. APPLICA'HON SUBMITTAL DATE:
DUNIT# LOT#
OWN,RS NAME: PIIONL: CONT CTOR'S NAM A LIC NO:
r� N/C CONTROL#
AHC III'I'ECT/F.Is 11 NE-LJS LIC NO: O ADDRE i ❑
Los 4"Aa. so C41I.
CONTACT: PHONE: BUILDING PERMIT INFO
Ql'Y. ELECTRIC PERMIT FEE
L �S UC ELF. PLUMB F,CH
PERMIT ISSUANCE / ❑
LICENSED CON'TRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL. jiOBDESCRIPTION
❑`%Z I hereby affirm that l am licensed under pmvisionso(Cbapmr9(cmnmencingwith
FOOq Sector.7")af Division3 of the Businessand Professions Coda-and m 7
Any license is in PANELS `�
atU full force and effect. 1 UI'T02WAMP5
6Z W Licenu Clwz Lic.#
y Q a Date Convucmr 201-11X10 AMPS
F,Z ARCHITECTS DECLARATION OVER 1000 AMPS SQ. .FLOOR AREA S/SQ.FT.
z O a,— I understnnd my plans shall be used ns public records.
OZ_.n
P y�W SIGNS ELECTRICAL
gg�,LL
Licensed Professional
OWNER-BUILDERnIAemptform
mDECLARATION SPECIAL CIRCUIT/MISC.
W 1 hereby affirm that 1 am exempt from the Co professions
Cs Licenu Isw for Ne
1+131'-m¢ which followingreason.
Front to
construct,
Aber,iand priva,demolih,orre repair
city or county TIiMP.METER OR POLL INST.
O.] Mor t requires issuance.petals re aresth aheq improve,demolish,or repair any awmurt
YC) that he is
censed pursuant to the
theapplicantof the ch CopermiOofile a Licese La statement POWER DEVICES
OUR that he is licensed pursuant m the provisions of the Conbanors License Law(Chapter
aao�' 9(commencing
xemwith pt therefrom
S retro and the
the
o Adus,lla Business And,Anyvom Code) SWIMMING POOL ELECTRIC VALUATION
-;y Secah7031.5 by
applicant
the herist subjects
thedexempti to civil plalty.f,on of UTLEfS-SWITCIILS-PIXTURCS
YQ
Section 7031.5 by hundred
domrs($50rmitubjttts the applicant toecivil penalty of ' C.JCJG/
not mom Nen livehunJred dollars(SSW). NLWRESIDENTIALELECfR _SQ.FI'. STORIES TVPECONSTRUCI'ION
K� pro ❑ 1,asownerofthepmpeny,ormyemployeeswithwagesmtheirsolecomKmauon,
a _ willdothe work,aniline suucwre isam intended proffered forsnle(Sea]044,Business -
g and Profession's Code:The Contractor's License Law does not apply to an owner of
properry whobuildsorimprovesthemon,andwhodoessuch work himulforthrough his OCC.GROUP RES.UNITS
own employes,provided Ihm such improvements um not itumded m uffeced for sale.If,
however.the building or improvement is sold within one year ofcompledon,the owner-
builder will have the burden of pmving that he did not build or impmve for purpose of
sale.).
❑ I,mownerofthepropen.nmexclusivelycontraningwiNlicensedcont.et.,In QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
e
nnstmct the project(Sec.704W,Bminexa end Professions Code)The Contractors
License Lawdoes notapplyman ownerMpmpenywhobuilds orimprovathcrar and PERMIT ISSJANCE
who contracts for such projects with a contracums)licensed pursuant India Contmetore
License Law. ALTER (PA) PEE SUMMARY
❑ 1 am exempt under Sec. ,B At PC for this reason BACK FLOW PROTECT.DEVICE OUTSIDE HER
SANITARY Y N
Owner Dam RECEIPT#
• DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION ofco DECLARATION SCHOOL TAX Y N_
❑ Ifterabers'Co afOsm Nn Insurance
certificate canumme.f(Snsure,m Lab C.))which
ftECE1PTp
Warker%Compensotion lnsurencmrecenifiedespy Nereo((Sec.3800,Lab C.)which Fl%TURES-PCR TRAP PARK FEE YN
covers all employee's under this pennip GAS-EA.SYSTEM-1 INC.4 OUTLETS
RLCEIPTp
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER4(EA) PLANCHECK FEE 0
El
copy is hereby furnished.
❑ Certified copy is fled with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP IsO FEL
COMPENSATION INSURANCE
(Thisuction need not be completed ifthe pemnit is for one hundred dollars(810)) SLWER-SANITARY-STORM LA.200FT. FE
or less.)
I codify that in the performance ofthe work for which this permit is issued,I mall WATER HEATER W/VENT/LLECTR
not employ any person in any manner so os w became subject to the Workers' P D
Cpmpertsminn L.awsof Celifomia. Dae WATER SYSTHWOBATING are Receipt#
O Z Applicant
O NOTICETO APPLICANT:IL.fm,making this Cenifcamof Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
4 becomesubbs,t to the Worker's Compenselm.provisions oftbe Labor Cole,you most
7 forthwith comply with such provisions An this permit shall he deemed revoked. BUILDING HE
W �-t
y (]
CONSTRUCTION LENDING AGENCY SEISMIC PEE
V 7-. Iherehy affirm thenhere is aconswetion lending agency for Ne pertormanee of
Ne work(or which this Permit is issued(Sm.309],Civ.CJ TOTAL: ELECTRIC HE
Q Lender's Name
L. PLUMBING EEE
I c I
U Iona Addreaa QTY. MECHANICAL PERMIT FEE Sl certify that I have reap this city
and county
and stem nces the above information is MECHANICAh FIiE
'ren. legrec to comply with all city wdcoumy ordinances and slam lows mleting to PERMIT ISSUANCE I� ✓
building construction.and hereby authorize representatives of this city mender upon the CONSTRUCTION TAX
U Z above-mendonedpmpoty far inspection pnmsmrs. ALTLR OR ADD TO MECII.
(We)agree to save,indemnify and keep hamnless the City of Cupertino against
Iildhhies,juJ meats costs um xpenseswhich may many way oceme egoinsuaiA City AIR HANDLING UNIT(TO 10,1100 CRM)
In copse uG fl inf Nis Permit.
o AIR HANDLING UNIT(OVER IQOW CFM)
S atureof ApPli.acWCnlm Date EXHAUST HOOD(WDUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam Receipt#
Will The applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100.0i BTU) TOTAL:
m defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cod,.Section 25532m)? ,y VENTILATION FAN RFSID)
13Yes !D_Ck\. /k
Will Ne appl icam or(wore building«cupant uu cyuipmem or devius which emit
BOILER-COMP(3HPOR IW,BWBTU) (1AII I IJa.l(fSSLLA.NCEDATE
hazardous air conuminants As defined by the Bay Are.Air Quality Management BOILER-COW(OVER 100,000 BTU)
Di,mst? V6619 Z gab
❑Yes � NEW RESIDENTIAL MECH. SQ.FT.
1 have read the lizzSafety
Code,
materials 5505.25533 under Chapter understand
of Ne ® O d
California Health @Safety Cade,Seaiom 25505.25533 and 25534.1 understand Jai G!1
iI the huiltl'tg dues of cumemly hevcatenan6 that it is my responsibilitymnotify the
mcupum Nc re em hick must be mu prior to Issuance of•Certificate of
O ����--���71l
Own uramhorized agent Dam T ISSUED BY
OFFICE