26576 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY V
CITY OFCUPERTINO krDbL .-E.E TRI AI. FERMIfNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 26576
BUILDING PROJECT IDENI'IFICA'I'ION
BUILDING ADDRESS: gy SANITARY NO. APPLICA'DON SUBMITTALDATE
S Tip , r (0`5-1 t4
UNIT# LOT#
OWNERS NAME: PHONE: CONTRACTOR'S NAME: LIC NO: N/C CONTRO p
U N1 L//La��A�''Q11 ,,rr�S NNom-- p -1.. �qn
•ARCIIITECT/ENGINE[R: LIC NO: 11"IS:C4ALC Ln tp JVD PLO ❑
CONTACT:
"�"// �r��� p..p �,( HONE'
( BUILDING PERIIT INFO
I v{Jfj V k I t 4c-5 6 �P5-7.0(y'V QTY. ELECTRIC PERMIT FEE
L BG ELECT PLUMB MF
PERMD'ISSUANCE �—
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL.
Oyy Iherebyuffirtn thatlamlittmM underprovisionsnfClupar9(cotmnencingwith JOB DESCRIPTION
FJ00 Section 70fl)of Divishm3 oflhe Business end ProfessiortsC e.end my littnse is in PANELS
full force and effect. N//N�N11
FU License Claz, Lich 5aa UPT0200AMPS S
v'cli Date Canwctor II 201-IIXltl AMPS SQ.FT.FLOOR AREA SSE.FT.
,z ONy CIIITECTSDECLARATION OVER 100(1AMPS
CZ-0 I understand my plans shall be used as public retards.
�rn�J
SIGNS IiLECTRICAf. AQf� rn 7—
OWNER-BUILDER
Q .J Licensed Professional �'f o Yf' L—
�C Yy.C< OWNER-exempt RD the Com9'ION SPECIAL CIRCUIT/MISC.
OaU 1 hereby as aft ium that 1 am exempt front the Cessm.Cs License Law for the
LL3LLy following mason(Senion]OJLS,Business and Prolasiov Cod<:Any city or county TEMP.METER OR POI.Ii INS'I'.
F�O J which regains a permit m construct,a er,improve.demolish.or mpair any structure
�a� prior mitsiasuance,nlm rcyuircs the applicam for such permit o file aligned statement POWER DEVICES
adom that he is licensed putiumr0o the provisions ofthe Conrrecmra License Law(Chapter SWIMMING POOL ELECTRIC VALUATION
LL 9t hat(commencing
xemwith therefrom
fromandthe basis
Jeflle Business and ProfessionsC..de)
onhohcisexbyanyaf.om and the permit
ects thedexemaromm Any ivilpeadonof OUTLETS-SWITCHES-FIXTURES
F Q nation 7031.5 by any applicant for n permit subjects the applicant to a civil penahy of /
not inner than rofthive nrodrtylarmyemp' NEWRFSIDENTIALELEUM t9f5 .PT.
uCuJ � ❑ I,aowneroDhepmperty,ormycmployecswiN wegeaeatheirmlecomperraation. Q STORIPS TYPECONSTRUCTION
y3— will dotbework,and the snactureisnot imendedoroffered fo.sale(Sm.]044,Business
and Professions Code:The Contractors License Law does not apply to an owner of
progeny whubmidsorimproves 0erean,emd whndoea such work Nmadforthroughhis OCC.GROUP RFS.UNI]'S
own employees,provided that such improvements we not amended or offered for sale.If,
however,the buildingor improvement is sold withinone yearofcompletion,the owner- TOTAL: 3 •3
builder will have the burden of paving that Inc did not build or improve for purpose of
e.).
❑ I,asowne.afthepmpeny,amexclusivelycnntaatingwithliceasedconraeorsm QTY. PLUMBINGPERMIT FEE FLOOD ZONE "N
consume the project(Sec.7144,Business and Professions Code)The Conuucmr'e PERMIT ISSUANCE `
License Lawdocs nm apply mi nownernf pmpeny who builds...improves thereon,and "Z•U 4
who contacts forsuch projects with acontrector(s)licensed Intention mine Contractors
Licnse Law. ALTER (FA) FEE SUMMARY
❑eI an exempt under Sm. ,B&P C for this reason BACK FLOW PROTECT.DEVICE. OUTSIDE
SANITARY Y_N
Owner Out f100R,ROOF,AREA.GOND. RECEIPT It
DRAINS
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ ens'Cu peroffmthatiheve a ace or.ficati otim,niermf(er.380.icar,or Lato .)whichficale of RECEIPI'N
Workers Gtployeas undertnmcermit. ified copy Mereof(S¢.Jg00,IabCJwhich I'1%TURFS-PPR 3'RAP PARK FF.Ii Y—N
—
covers all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy p BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PfANCHECK FEE -�
❑ Cmified copy ie hereby furnished.
❑ Cenifed copy is filed wiN the city inspection Jivisinn. GRFASE)INDUSTRL WASTE.INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE
This section need not becompleted ifthe permit is forore hundred dollars($100) SEWER-SANITARY-STORM EA.2001T. ENERGY FEE to,.
or less.)
I certify that in the performance of the work for which this permit is issued,l shall WATCR I IEATER W/VFAT/ELCLTR
not employ any person m any manner so as to became subject m the Workers' PAID
Compensation Lawsol Califomia. Date WATER SYSfENIMREATING Done Receipt#
Q z
NOTICE
NEW RESIDENTIAL PLMfl. SQ.FT. �� TOTAL:
NOTITO APPLICANT:IL m
after making his Cenifiwm ofEumptlon,you should
fq bomere subject to the Worker's Compensation provisions of the Labor Cade,you must
forthwith comply with such provisions or permit shall b,domed revakM. BUILDING FEE ESTsOT
a [� CONSTRUCTION LEADING AGENCY SEISMICFEE
z I hereby affirm that he.is is mnsumeiom lendingagency far the perfmadomeof � Q
L) O NTOTAL:e work for which this Permit is issued(Sec.J(5].Civ.C.) • J�!, ELECTRIC FEEI 37
Lender's Name
0t' Lender's Address QTY. WCHANICALPERMIT FEE PLUMBING IEE 137-S3
L) 1 certify In.1 have read this application and stare that the atwve intonation is MECHANICAL FEE
r�" a coven.l agree to comply with all city and county ordinances and sure laws relating to PERMIT ISSUANCE
�•' FA buildingconstmction,and hereby auNoriu«presemadveso(this city to emu
erpon the CONSTRUCTIONTAX
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgmenu.costs and expenses which may in any way accrue against said City AIR I IANDLING UNIT ITO 10,(100 CFM) Iry
intron. afrac gramin of Niap it.
AIR HANDLING UNIT(OVER 10,000 CFM)
Slgnammaf Applicant/Conuarba Ip gone�- EXHAUST HOOD(W/DUCT) _ PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Done Receipt#
William applicant or future building ettupantatme or handle haardous materiel HEATING UNIT(OVER 100,(100 BTU) TOTAL:
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 255320)Y VENTILATION PAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
Will the acona rnnr fuare building by the,useBay equipment Quality
BOILER-COMP(JHP OR 100."BTU)
huarict? air contaminants az defined by the Bey Area Air Quality Management BOILER-COMP(OVER IW,1g10 BTU)
Uiavics]
❑Ya ❑No NEW RESIDENTIAL.MECH. SQ.FT. O OCT 12 1994
x
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sectimrs 25505,2553]and 25534. I understand that
if the building does not cunently have a reman6 that it is my respmrsihi lily to witty the yl ht Vl• l/61-at(IIAU
r of the requirements which must be met prior to issuance of a Certificate of
Ocsupecupancy. c
Owner or amhom<d agent - Date TOTAL: 'ft.? ISSUEDBY:
OFFICE