26080 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY ,
IIUILDI :-EL1•.f:'I'NICAI, PI?RMI'1'NO, n \"
jkRCHCT/ENGIN'ER:
CUPERTINO I'hI1MIiINC-MN:Cf1 ANICAL 2 O O 8 �1
BUILDING DIVISION APPLICATION/PERMIT IIUILOING PROJECT IUEN'TlFIf,A'TION s
SANITARY NO. APPLICATION SUBMIT'T'AL DATE
DRESS: wyw //
J L,-, ITP LOT#
E: PHONE: CONI' COR'S NAM14. LIC NO: NIC CONTROLp
t �
LIC NO: ADDRL'SS: 'JS ❑
CONTACT: - / —PHONE , QTY. ELECTRIC PERMIT FEE BUILDIN .. LU.MB O
ELECT PLUMB MECIi
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DP.SCRIFTTON
I hereby refRrmthat l am licensed underprovisionsofOupter9(commando,with 11
QP OO Section 7000)of Division 3 tribe Business and Professions CWe,and my license is in PANELS � f[&C,- G Lk4 m.5.w
w� full force and effect.. y q� p
FZ,tyLicense Class !' 99 Lit. S9Z�fr IJPT02MAMPS
m6teie Date Comructor 201-IINMIAMPS / L is.k( •a-C1�0' _
F,'z ARCHITECTS DECLAMATION OVER IIXX)AMPS 5 P R A A S/SQ.FT.
z O m— 1 understand my plans shall be used ns public records. � N
OZF W SIGNS ELECTRICAL
Q��,'4j Licensed Professional 1�
TER
d''CQ OWNER-BUILDER DECLARATION SPECIAL CIRCUTOMISC. a r
ts'Oa. I hereby affirm that I am exempt from the Conuadors License Law for the
following mason.(Section 7031.5,Business and Profession,Code:Any city or county TEMP.METER OR POLE INS . 6I/
I tILOwhich requires ape.I,to convect,al¢r,improve,demolish.m repair any structure
DATE
��¢� prionoits issuance,also rcquims the applicant forauch permiuo file osi,md structuralPOWER DEVICESNal he is licensed parsman to the provisions of the Contractors License Law(Chapter
tido 9(corunencing with Session 7")of Division 3oDhe Ba,mess and Poofessicns Cartel SWIMMING POOLP.iCIRIC L VALUATION
W=mor he is exempt therefrom and the basis for Ne alleged exemption.Any violation of OVI'LETS-SW ZIPS-FI%TURIS 71 II 5 3 S. �o
�z< Section 7031.5 by any applicant for a permit subjects the applicant to a civil pencil"of
n.=O noumre than five hundred dollars($500), NEWRESI IALELF.CTR _SQ.IT. STORM'S TYPE.CONSTRUCTION
WF� ❑ LasownernfthepropenY.ormyemployeeswith wagese.+thcirsolecompemation,
d3— will do the wofk,anddeswcmrc is not maeolesimuffercd for saleSer. 044,Busiaess
end Professions Code:The Comrectofs License Law does not apply it,an owner of
property w2obuildsorimproves thcreon,and whodms such work himselforthough his OCC.GROUP RES.UNITS
ownemployees,providential such improvements arc not imcnded m offered far sole.If.
however,the buddingor improvement is sold within one year ofcompletion,theowner- TOTAL:
builder will have the burden of proving Net he did nm build or improve for purpose of
sale.). QTYPLUMBING PERMIT :FEE FLOOUZONE APN
m
❑ I,saownerofthe property,man exclusivelyconuacting with licensed contracts.nn ,
onsuuct the pooped(Sec.1044,Business and Profession CW-de)The Contmctora PERMIT ISSUANCE
License law does not apply to an owner of MnPcny who builds or improves nheremm,anJ
whocmmracts bersuch projects with acomracmK,)licensed pursuant m the Convectors ALTER-DRAINis VEhIT-WATER MA) FEE SUMMARY
License Law.
❑ 1 am exempt under Sec. .B&PC fir this recon MACK FLOW PROTECT.DEVICE UTSID
SANI'T'ARY Y N
Owner Oat° RECEIPTp
DRAINS-FLOOR,ROOF.AREA,GOND.
SCHOUL'I'AX
WORKMAN COMPENSATION DECLARATION Y N
❑ Thereby affirm thanlhaveacenificatu of consent no ulGinsure.oracenif ale of FI%TURFS-PER TRAP RECEIFI'#
PARK FEL'
WorkerCopensation lnurameora cersified copy Nereof(Sec.3800,IAbC.)which Y N
sm
covers all employee's under Nrmit is peGAS-EA.SYSTEM-1 INC.4 OUTLE' RECEIPT p
BUILDING DIVISION FEfS
Policy N
Company GAS-EA.SYSTEM-OVER 4(EA PLANCIi[CK ItF.
❑ Certified copy is hereby famished.
ja CenifiW copy is filed with the city inspection division. GRIiASFJINDUSTRL WAST' NTTiRCf:PTOR GRADING PLE
CERTIFICATE OF P-MPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE.
(This section need not be completed ifthe permit is(crone hundreddellars(S10() SEWER-SANITA -STORM KA.200F11 ENERGY FEE
or less.)
E certify that in the performance of the work for which this permit is issued,Isha11 WATER HEA96 WNENT/ELECIR
not employ any person inany manner so as toM);oy�'sub'ect to the Workers' PAID
Compensation laws of Califo DatS -A- qW WATER STEMITREATING Date Receipt#
O Z Applicant Ji14 fL'GI
Z 0 NOTICE TO APPLICANT:If,efmr making Nis Ci,ofmdenf Exemption,yoashould NEW F:SIDENTIAC PLMB. SQ,17. TOTAL:
Fes. becomesubjectmNe WnrkeraCompcnsmion provisionsof Ne laborCWe,youmoa. /
� , forthwith comply with such provisions or this permit shall M deemed revoked. BUILDING FEE
(] CONSTRUCTION LENDING AGENCY SEISMIC PER
Z1 hereby affirm the dame is a corenuction lending agency for the performance of
O Ne work for which this permit is issued(Sec.3091,Co.CJ TOTAL: ELF.CfitIC FEE
Lenders Name PLUMBING FEE
U-' F Lenders Address Ql'Y. MSCI IANICAL PERMIT FEE
U I certify that I have reed this application and ands that the above information is MI?CHANICAL FEE
>" W correct.I agree to comply with all city and county ordinances and state lawsrelating to P17RMI'1ISSUANCE
I-' N building construction,and hereby adhone,represendtees of Nis city to enter upon the CONSTRUCTION TAX
UZ above-memmued property for inspection purposes. ALTER OR ADD TO MECIL
(We)agfm tu save,indemnify and keep hamtlesa the City of Copeman,against
liabilities,judgments,costs andexpenses which may in any way accrue against said City AIR HANDLING UNIT(TO I0,000 CFM)
in consequence of the granting of this p rush.
AIR HANDLING UNI'((OVER 10.00CFM)
FM)
Signature of Applicant/Contracmr Dale EXHAUST HOOD(W/DUC1) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I Oo,WO BTU Date Receipt#
Will Ne applicant or future building occupant same to handle hazardous material HEATING UNIT-(OVER 10(1, BTU) A
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health cad Safety
Code,Section 25532(x)? VENTILATION PAN(SI SLE RESIDI
11 Yes C3No
ISSUANCE DATE
WIIHheapplicanmrPomra buildingoecupant aseequipmenmrdeviceswhlch emit BOILER-COMP(3 OR 1110,000 BTI) PAID
hazardous air contaminants as defined by the Bay Arc.Air Quality Management BOILER-COM OVER 1011,000 BTU)
District? /j
EI yes ❑No NEW RISH ,NTIAL MECH. SQ.FI'. ('TPR 13 7994
I have read the hazardous materials requirements under Chapter 6.95 of the
California llcalth&Surely Code,Sections 25505,25533 and 25534. 1 understand that CIiY ser
if the building does not currently have a tenant,that's is my respomaibibly to notify the �urcrr I II�V
ccupart of the requirements which must he met prior to issuance of a Certife ns of
o
ecu
Opan y eM//, yJialg�
Owner or aunM1orizeJ cul Y/ Dole TO'fN.: ISSUIiD BY:
OFFICE