26303 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBmI7i11vG- J'E PERMIT NO.
APPLICATION/PERMIT 1'LLIMBING-MECHANICAL O
BUILDING DIVISION BUILDING PROJECT IHENTIFICA'1'ION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
UNIT LOT#
IiRS NAME: PHONE: CO 'RACTOR'S NAME: CoN LIC NO: NIC CONTROL#
�ti - -7
RCHITLCf/ENGINEER: LIC NO: ADDRESS ❑
D- 80 43 LaaDda 5
CONq ACI': PHONE: AJ, ;}_. g? . r# r•'€BU'ILD'ING PERMI'C INFO
r` /�/ '7/J/J Q T tgp ELECTRICfi4lMi ' FEIi
ay (JCjlm 3 J(p _C 5 %� PERMIT ISSUANCE
It _ -1 BLDG E PLUMB MHCH
El 1:1LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB MCRIM ION
OtuCZ Iherebyaffimen
uhat l am licsedunderpaisimof
vs ainne,9(armmancing with
0.00 Section 7000).&Division 3ofthe Business and Professions Core,and my license is in PANEL$.
yzw8-. full fnrc<und effect �/
FZaVt Datan_7'7�Lic.p IIP T—i""P5
rn=It Darc Conmctor N A)N(� 201-1000 AMP$
ZOsiana z' ARCHITECTS DECLARATION OVER 1(00 AMPS SQ.FT.FLOOR ARU S/SQ.FT.
CZ-0 I understand my Plans shall be used v public records.
E C m SIGNS ELECTRICAL
WS4 -_1 Licensed Professional (�
wx< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT IS .
a'Op�,U 1 hereby affirm that I am exempt frc n the Commerce's License Isw forum
fallowing amer.(section 7031.5,Business and Profusions Code:Any city or county TEMP.METER 01 WST.
�J which requires a penal m construct,that,improve,demolish,or repair any structure
�yWY� prior m its issuance,also requires datmlicanl f.rsucb permit to file a signed statement POWER DEVICES
W E O 0 thm he is licensed momam to the provisions of the Cma a roex License Law(Chapter
P. n 9(et mencing oah Section 7000).17 Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC 1 VALUATION
i�_y or llmt M1e ie eannpt ihercfrnm end the basis for the ullegeA exemption,Any violeticn.f OUTLETS-SWITCHES-FIXTURES 1 OC.)2 Section 7031.5 by any applicant for a permit subjects the applicant a civil penalty oflAi ` (�
Mnot m..than five hundred dollars($500). NEW RESIDENf1AL BLECfR S .FT.
C o ❑ I,asownerofthepro ray,ormyemployaswithwtgesastheirs.lecomp madon, Q STORIES TYPE CONSTRUCTION
o0 willdaim work,and the shumureis not inteadedorofferad for sale(Sec.7044.Business
and Professions Code:The Conuamor's License Law does not apply to an owner of
property whobuildsor improves Nereon,and whadaas such we&himselfor through his OCC GROUP RPS.UNITS
own employees,pavidedthat such improv min¢
improvements anm ndWoroffered forsale.If,
however,the building or improvement is sold withinone ysaro(mmpletion,the owner- r
builder will have the burden of paving that be did not build or improve for purpose of
sale.). -
❑ I,as owmaoffie propeny,ver exclusivelyconmcling with licensed contractors in QITYI PLUMBINOPCRMTp FF.E FLOODZONE APN
onsnue,the project(Sec.7044,Business and Profesums Cade:)The Contractor's PERMIT ISSUANCE
License Lawdoesnnt apply toss ownerofpaperry whobuildsorimpavesli erten,and
%hoconlmcisforsuchpmjectswithacmn toos)licemedpursumtlotheConh was IN Licamc law. ALTER
FIiE SUMMARY
❑ 1 xm exempt under Sec. ,B&P C for this ream. BACK FLOW PRO'IIiV
'ECf.DICE TSIDI :h.
/ NITARY Y_N
Owner Dam RECEIFI'#
TIDRAIN,
-FLCU cO ,AREA,C
ly WORKMAN COMPENSATION DECLARATION HOG.TAXN_
1 hereby off rte that 1 have a certificate afterward to self-ins......certificme of H iCEIPI'p
or I, Compensation Insurance or acenified copy thereof(Sec.3800,Lm CJ which TEXTURES PER TRATr
PARK •E Y N
revers sellee'a under .this peomiL 02 GAS-U. IINC.4 Of r1fi IS RECEIPT
......
Policy p TNG DIV
Company GAS-EA.SYSTEM-OVER 4(FA) PIANCHE
❑ Certified copy is hereby furnished.
❑ CenifiM copy is filed with the city inspection division. GRUS191NDUSTRL WASTE INTERCEPTOR GRADI -E
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP
COMPENSATION WSURANCE
('This section need nm be completed ifthe permit is foeom hundred dollars($100) SEWER-SANITARY-STORM FA.2WIT. ER(V FEE
.r lwa.)
I certify that in the performance ofthe work for which this Permit is issued,l shall WATER HEATER W/VENT/ELEC7FR.
of cranny any person in any manner so as to become subject to the WorkersPAID
Compoaatiou Laws.f California. Date WATER SYSTHM/I'RHATINGTam Receipt#
Z Applicant 1
NOTICE'TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RBSI DENI'IAL PLMB. SQ.FT. 'T'O'TAL:
became subject o the Wo&els Compensation provision.of the l.bar Code.you..at
forthwith comply with such provisions or this Permit shall 4 demand revoked. BUILDING E �.
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FkE
1 hereby afford that them is a construction lending agency for the performance,of
U O the wo&I which this permit is issued(Sec.3097,Civ,CJ TOTAL: ELECTRIC it —
Isnder'sName - --
u" F Icndals Address QTY, MECHANICAL PERMIT( - FEIi
PLUMBING E
U I certify N®I have read this application and some that the above information is
cmrcc. lagmem comply with all city and county ordinmce,and some law a relminglo PERMIT ISSUANCE MECHANICAL E
F-' building crostruction,and hereby authonre representatives ofmis city roamer upon the CONSTRUCTIO TAX
U Z above-menlmood property far inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep hornless the City of Cupertino against
liabilities,judgmamE,rusts and expenses which rosy in any way accmea,uhut suid City AIR HANDLING UNIT(TO 10,000 CFM)
in c.nsupi oft 'r'. I ispemit.
AIR HANDLING UNI T(OVER 10,000 CPM)
SlgnmnafA Ile momm, Data IAHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000BTU) Date aceipt#
Wr the tpplwam or forum building ece.pmt store ar handle haxnrdaus matenat
as defined by Nc Cupertino Municipal Code,Chapter 9.12,and the Ileahh and Safety HEATING UNIT'(OVER UJEM BTI)) 'ITAL:
Code.Sermon 25532(x)7 VENTILATION FAN(SINGLE RFSTD)
❑Yes No
BOILER-COME(31 IT OR 100.000 BTU) 'E
Wm, iatriumphant,cant sbuiloadbythe useequipmir unlit comments hauNous air c.maminanu an defined by the Bey Area Air Quality ManagementBOILER-COMP(OVER 100,000 BTU)DialnLl7 ❑Yes �No NEWRPSIDENTIAI.MIiCII. SQ.FT.I have read the hazardous mmerials requiremema under Chapter 6.95 of thet,7kA�OANCE"I
Cullfnmia lleallh&Safety Code.Sections 25505,25533 and 25534.1 understand that
if the building does no currently have a tenant,that it is my responsibility to notify the
eeupmu ot'the requirements which most be met prior to issmmce of a Canifictle of
a.curyncy. •(V
Owner or i mmaized agem Date TOTAL: ISSUED BY:
OFFICE