26355 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RU".2,i.EEEETR]cAl PERMIT NO.
APPLICATION/PERMIT 'LUMBMG-MECIIANICAI- 26355
BU11.131NG DIVISION BUILDING,PROdE(,T IDR,MnFTCATION
BUILDING ADDRESS: '•''f SANITARY No, APPLICAI[OON SUBMITTAL DATE
� VV V
I � 3 1.FC/ ('
1Z6 l 67ZT_(n1 .UNIT. LOT is
OWNERS NAME: PHONE: CONTRACTOR'SNAME: LIC NO:
1imou5 Foo Twtaw- CO/v]/P2E2C1 /aL7E2HTroei $ 7 NX CONTROL.
A1R�CHITECTIENGINF.ER>: LIC NO: ADDRESS: ❑ �. Il n
]s,VIZT lq ERAI-6 C 54-- C6-ryT2AL A1.G b11'/9d2K Cp.94Sbv LOU '(10
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
/sL 571-�-7 �+ 9LI1G ELECT PLUMB M ICH
SI Gr'L10- 1 /I PERMIT ISSUANCE /� �Lnpl`
le� 0A
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DF.SCRIPI'ION
Q=z I hereby xlfdn that Hun licensed underpmvininnxofchapter9(cnmmencingwith e
u102 Sectimh]01Npof Division 3 atlas Humid.and Professions Code,and an,license ism 1 PANELS
FK�{� full force and eum,)3 _ 1 / 6
<jly License Class / -/' IIP T0200 AMPS
Lie.
h~n6d
par, '!-I•7-4 Co. � 201-1000 AMPS
Fyz ARCHITECTS DECLARATION SQ.FT.F1000.AREA S/SQ(FT.
Z07—M I understand my plans shall be used as public records. OVER IOW
FyCu] SIGNS ELECTRICAL
Licensed Prolessional
y d'Q OWNER-BUILDER DECLARATION SPECIALCIRCUMIMISC.
xOiu I herchy affirm that I am esern,from the Cannot License Law for the
tL 3 a y following reason.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE MST,
1- 0Q which requites a permit to construct,slur,improve,demolish,or repair my stmame
Vi_1
prior In its ismnnee,also requites the applicant bamch permit to file a sigmedmaremant POWER DEVICES
WKOp that he is licensed pursuant 1.]in provisions oIthe Contto
racr's License Law(Chapter WIMMING POOL ELECTRIC
Y C,o�' 9(commencing with Section 70N)of Division 3 of the Business and Professions Cade) VALUATION
y=Q or that he isesempt therefrom andthe basis for themlegcd exemption.Any violation of ETS-SWITCHES-FIXTURES l �� (/OD
F'_> Section 7031.5 by any applicant for a Permit subjects the applicant to a civil Penalty of 1 —(
W1= not m1, town rofthevc tore nylarmyomB. NEWRFSIDFNTIALELECIR _SQ,FT. STORIES TYPECONSTRUCION
KFo ❑ Lmownrk,multhemooarc is not
compensation,
a3e= will dothe won,andrhesw Contra not,Liomsn effirmol Law does a ,applyJ0up Boniness
and Professions ldsori pr Contmaors License Law dace not apply tow owner iof
s
properlywhebuildsorimprovesthereon,andwhodre noti tworkhlmnlfm flarril'Russia.his
own empinyees,pmvidedthet such improvemcnteu not inundedoroffemd forsale.If, I OCC.GROUP RES.UNITS
however,the building orimprovement is sold within one yeatrofcmnplemn.the owner-
builder will have the burden of proving that he did not build or improve for puryme of A E
sale.). QTY. PLUMBING PERMIT Z h N
❑ Laowner oftheproped"um exclusivelyroaniedn'with licensed contractors to
msmet the project(See.7(94,Business and Prole,slons Code.)The Contractor's
License Lawdoes not apply to an owncrof,um,edy whobuildsorimprovestmuon,and PERMIT ISSUANCE
who contract for such projects with aconractoom licensed pursuant tome Contractor's ALTER-DRAIN&VENT-WATER(EA) Y
License law.
❑ 1 am exempt under Sec. ,B&PC for this ruwn BACK FLOW PROTECT.DEVICE SIDE F:E -
SANITARY Y N
Owner Data DRAINS-FhWR,ROOP,AREA,COND. RECr;IP1'.
WORKMAN COMPENSATION DECLARATION SCI 1001.TAX Y N
❑ Ihcrchy effrm thallkveecenificau of consent toolf-insure,mncenifcan of FIXTURES-PER TRAPRECT;IPI'p
Workers'Con,eavrian Insurance ora cenifiedNerto10
cnpy f(Sm.38 ,Lab C.)which PARK FEE Y N
covers nllem loyec's under leis L RECEIPT.
p .it. GAS-EA.SYSTEM- INC.4 OUTLETS BU ILDING DIVISION FEES
Policy.
Company GAS-EA.SYSTEM-OVER 4(IA) PLANC DECK FEE
❑ Certified copy is hereby modified.
❑ Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE IN'rFRCEP1'OR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section noted not becomplcted ifthe permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.20017f. ENERGY FEE 270. 60
or less.)
I really lM1minthe Performance of the work for which this pemhil is issued,lfiall WATER HEATER WNENT/ELECfR
not employ any person in any manner m as to become subject to the Workers' PAID �� s
Compenwtimi Lawsaf California. Dau WATER SYS]EM/1'REATING Do¢ Recmphp
z t' Applicant yI
z O• NOTICETOAPPLICAW.1f,.fte,ma ,this CcnificauofEumpton,youshould NEW RESIDENTIAL PLMB. SQ.FT. d �—� TOTAL: /Q�7.,y
F' co become atibjecd to the Workers Compeman.provisions of the labor Code,you must
a forthwith comply with such provisions or this permit shall be rented BUILDING FEE Q revoked. �Z. I
[� CONSTRUCTION LENDING AGENCY SEISMIC FEE 2 x
1 hereby affirm that is a construction lending agency for Ne performvrce of
U zthc T ELECTRIC
U O La work far which leis permit is issued(Soc.309],Civ.CJ
Dances Name PLUMB IN
0 F L<neers Address QTY, MECHANICAL PERMIT FEE
1 readily that 1 have mad this application and slate that me above information is ME 'FEE
correct. l agree to comply with all city and county ordinances and slate laws relating inPERMIT ISSUANCE
F' buildingumsbuctiun,area hereby nuNome representatives of Nis city loennr upon the CONS ION TA
VZ above-mcmtioned p.upeny for inspection sn"m s. ALTER OR ADD TO MECH.
(We)agree m save,irWemnify and kmp M1mmleas the City of Cupertino against
liabilities,judgments,cost and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO I L"CFM)
in consequence of the grunting of this permit.
AIR HANDLING UNIT(OVER 10.000 CFM)
Signature of Applicant/Contmctor Dam EXHAUST HOOD(W/DUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,00(1 BTU) Date Receipt.
Will the applicant or future building occupant store or handle has burs material
as defined by the Cupertino Municipal Cade.Chapter 9.12,and the Ilealth and Safety HEATING UNIT(OVER 1 W,00(1 BTU) TOTAL,
Code,Section25532(x.sw VENTILATION FAN(SINGLI RESID)
11 Yes X No
ISSUANCE TE
Will the aWlicantorfutue buildingoccupsm use Wuipomoordeviceswhich emit BOILER-COMP(3HPOR 100,000BTU)
haardom air canumimaaB as defned by the Bay Ana An Quality Management BOILER-COME(OVER 100,000 BTU) p� pp p
imic4 r .sY Y
❑Yes �.J Nu NEW RESIDENTIAL MECH. SQ,FT.
I have Taxa the haeanlnus materials requirement under Cmprr 6.95 of the ��� 21 199
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand Nat /1
if the building docs not curri have a tenant.that it is my responsibility to notify the 7
occupant of the requirements which mum be mel prior to issuance of a Cenificate of eta r Lrr nh �(a
Occupancy. ,;� ,/�j1Y
Owner or waiud agent Data TOl'AL. ISSUED BY' y� //kkT'pPy'Ypa�11``�F71