26245 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - inDl'Ulm IN-L"MURICAL PERMIT NO.
BUILDING,DIVISION APPLICATION/PERMIT PLUMBING-MRCHAN'ICAI.
BUILDING PROJB.CI'IDEN'1'IN'ICA'TION 26245
Bull.DINGA,D`DRE55: C SANITARY NO. APPLICATIONSUB�MIkTI'AL DATE
2C3 �+ UNIT# LUI b �-^�O"Q
OIARS NAME: PHONE: CONTRACPOR'SNA ' LIC NO: _\
PH N/C NfROLp
RCHITECT/ENGINEER: LICNO: ADDRESS: ❑ ki
}pJ�
{N PHONE: °.`� BUILDING PERMIT INFO
QTY.; t ♦aj ELECTRIC.PP.RM7T FEP.
J �♦ n)3
PERMIT
I )UANCE ESLD_:T 'L� U� P
6 PPRMIT ISSUANCE
LICENSED C TRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
0`XZ Ihcrebyaffinotho larnlicenud and<rprovixionsofChepter9(contmencingwith JOB DESCRIM ION
FOO Stuio.70(IIBof Division 3ofthe Briammaand ProNesi...Code.ardmylice renin PANELS �7`
aUF full forocund effml. UPT0200 AM
FZIY License Class Lic.q
m6vR'i Date Contractor 201-U)W AMPS
F v Z All DECLARATION ¢ S .Irl'.F1.00R [� $/SQ.FT.
ZOy•• OVER IODO AMPS I—. �,ys .�
O Z^c, 1 undersand my plans shall be used n Public records. f'� �y q �—
F y X t SIGNS ELECTRIC 1 i1 ✓ I I V
Q , Licensed Professinnvl V
q d'Q OWNER-Bempt for.
DECLARATION SPECIAL CIRCUIT SC.
OyO 1 hereby affirm ti nt 1 mr exempt from @a Conuanoro License Law for the 'Dpnn_' GG
m i,ovFi following reason.(Section 7031.5.Hartness and Professions Code:My city or county TEMP.METE OR POltyp�`
UR'O¢ which requires a,mariue consvucLvlmr,improve,demolish,orn it any swnum __
�Y� prior to its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICP.S
<0 K Q O that he is limmod pursuant to the provisions of the Contractor's License law(Chapter
aq Gs 9(cnmmcncin with Section]OgOofDivisionJof the Businen end Profeeaiore Cale SWIMMING POOL ELECTRIC
xo4 g ) �� VALUATION
1_y or Section
he is L.5 mpt byrthere0umnndthe basisfartheritged,licauinn.Aryl violation OUTLETS-SWITCHPS-FIXTURES IJ.MA
F Z Q, Section]Ol L5 by any applicant for a permit mbjecu @e npplimnno a civil penalty of sill.(f
not ore th an fivo hundreA doll ars($500).
C O l,asownttof the ro norm em to eeswith va militheirsolecom NEW RESIDENTIAL ELECfR _SQ,FT.
o P Pe Y Y D Y g pensetion. S'I'ORIIiS TYPE CONSTRUCTION
yam wr 0the work,andthe sbuctule is not intendedoroffered forasle(Sm.7W,Business
and cs.ions Cade:The Contractor's License law does not apply m an owner of
propm who builds orimprovcs thereon,end whodnessuchwnrk himulfor Nroughhis
ded thatsuch imp mrtim
roveemaamot inndedoffered forsale.If, OCC.GROUP RFS.UNITS
hocrapIoyees,pmviwever,the building or improvement is wild within one year ofcompletion,Ibeowner- TO
builder will have the burden of proving that he did not build or improve for purpose of
arae). QTY:; . -PLUMBIN&PERMIT ..FEE FLOOD ZONE. APN
❑ Las the pr al ject(Sm.7G , exclusivelyBusiness
sam Profie Ing with lTccnud Conti o t 'x "
construct the project(Sec.osupo derofaa and ywhob builds
Crimp]UG,thenvamadd PERMIT ISSUANCE
License Law does not Apply uannwncrof propeny who builJs or improves thereon.add
who contracts forsuch projecm with.carvmomp)licmaed pursuant m the Conbactor's
MARYLicense Law. ALTER-DRAIN@VPNT-WATER(IA)
❑ 1 am exempt under Sec. ,B @ P C for thls reason BACK FLOW PROTECT.DEVICE OU[SIDE -:.S
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPfp
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN_
I hereby affirm lhetlheve accnifcme of consent ulGireurt.ora certificate of IIXTURES-PER TRAPICD RIiCEIFT#
,Norkers'Compensrtion Insurance Ora certified copy thermf(Sec.3800,Lab C.)which PARK FEE Y N
rsoo,na all employee's undenhis Permit GAS-BA.SYSTEM- INC. OUTLETS RL "III#
Policy BUIL ISION FEPS
Company GAS-EA.SYS'I'EM-OVER 4(EAI PLANCHECK FEE
❑ Certified copy is hereby famished .
❑ Cenifed mPY is fled with the ciry inspection division. GREASEjlNDUS'rRLWASTF.IMERCEPTOR GRADINGFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEH
COMPENSATION INSURANCE
(This section reedit he completed ifthepnmit is failure hundred dollars D 1W) SEWER-SANITARY-STORM EA.2WIT. ENERGY FEE
airless.) 1�5 IF
I cenify that in the performance ofthe work for which this pemrit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so es 1.become subject ro the Workers PAID
Cpmpenamion Lawsof Califimia. Date WATER SYSTF.M/fREATINC Date Ra
O z Applicant C
z 2 NOTICETOAPPLICANT:ILaftermakinglhis Cenifcateof Exemptiogyoushould NEW RESIDENTIAL PLMB. SQ,FT. TO AL:
(~ Ct) become subject to the WorkersCompensation provisions ofthe L.bm Code,you must
� ' forthwith comply with such provisions or this permit shall he domed revoked. BUILDING FEE _fey
Z
CONSTRUCTION LENDING AGENCY SEISMIC PLE
s-� I hereby affirm met them is a construction lending agency for the performance of ELF.CIRIC I£E
U O the work for which this pemtit is issued(Sm.3097,Civ.C.) WIN
ti
Lenders Name
W F LendWa Address QTY.- LjMECHANICAL PERMIT = 'PEE PLUMBINGFEE
U I cenify that 1 have read this application and state that the above information
correct Iagree mcomply with all city and county ordmencn end emmiews relating to PERMIT ISSUANCEvw� MECIIANICAL FEE
buildingconuunion,and hereby endocrine repleuruivesofthiscity Inernmvpon the CONSTRUCTION TAX
V Z mo,c-memioned propeny far inspection purposes. ALTERORADDTOMF.CH.
(We)agree to save,indemnify and kmp himmoss the City ol'Cupenom against
litbilitin,judgmems.cora and experts whEhor,loony waymmueegmust said City AIR HANDLING UNIT CFO IO,OW CFM)
u Ice O(the antingoflhis'no t.
AIR HANDLING UNIT(OVER I0,000 CFM)
Slgnmu ul Applicam/Contractor I Dme EXHAUSTHODD(W/DUCT) 1
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,00f1 B'fU) Dme Rueiptb
Will the applicant or future building occupant store or bsnJle haaardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNJT(OVER 100,000 BTU)) I Tqliw
Code,Section 25532nd? "ZM
VENTILATION PAN(SINGLE NH91D)
11 Yea ID No
BOILER-COMP(3HP OR 100(100 BTU) ISSUjCN ril
TE
Will lheapplicnntor future building occupant use eyuipm ,
entnrdevices whichemit Y TE
hwallovs air mnuminanu as defined by the Bay Area Air Quality Management BOILER-COMP(OVER�' 100,000 BTU) aI m.
uin ❑ C]P 87 r�1 19g�
Yes No NEW R1351DEN'f1AL MfCH. SQ.FT.
I have lead the haaamoue materials requirements under Chapter 6.95 of the C//`''Gr- O
Cvlifomin I leahh @Safer Code,Sections 25505,25533 and 25534.1 u alcomm l Thal I V LL ^
ifthebuildingdonnotrents yhaveast be Thatitis mytespnceof a enotify
occupant of the mprirementa which must be ma poor ser issuance of v Certificate of
Occupancy.
Owner or amhoriud agent Date T '1ISSUED BY�1/� l 1
OFFICE