26251 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - . .r.ECTm, . PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. 2625 C
BUILDING DIVISION BUILDING PROJECT IDENTIF'ICA'TION v J
BUII.DINGADIlRESSy� � �� UNITp LOTH SANITARY NO. APPLICATION SUBMITTAL DATE
O h NAMIi: ' PILON- CON RL tS AM' LIC NO: N/C CONTROLp
ho l(� 11` C &J—
CONTACT:
a�7
r�RCIIITECT/rNSIINP.CR: LIC NO %I�V V� C.JIJ ❑
CONTACT 1J�i PHONE: n /s,, Q.py. &!,�s LI+P(sTRIC PF-RIvIIT. -s'+,'.EER• -BUILDING PERMIT INFO
Q/I _/ td.£•;§Y-. BLDG ELECT PLUMB MECH
CJ If/N/7 a(���(, PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL.
M,az I hereby affix that l am licensed under pmvisionsofOhaprer9(commencing with LOB DESCRIPTION
QW C full orce and OO Suctiml effof Drvision 3 of the Business I Professions ode,end my licenx is in PANELS
F'zL Licensa, Lic.N IIO'f87 �/J�/ IJP T0200AMP5
F]y Dale s Conlreclar (X(/( 301-I000AMPS
ZOyE' ARCIIITECFS pECLARATION OVER IOW AMPS SQ.FT.FLOOR AREA S/SQ.FT.
O Z_Q I understand my plans shall h used ns public records.
r Nt:�� SIGNS ELECfRIt1V.
J OaF Licensed Pmfesmonol
rOWU OWNER BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
xI hereby nouns Phut 1 am exempt from the Contimmois License Law for the
1a13�Q following cas°a(Section7031.5,Business and Pntfammis Code:Any city nr courtly TEMP.METER OR POLE INST.
which termites a permit to construct,eller,improve,demolish,or repair any rwcNm
prior to its issuance,aim)requires the applicant for such Pamir o file a signed statement POWER DEVICES
w p O that to,,is Iloonsed pamumm to the provisions ohho Comruclor's License Law(Chapter
sty 9(commendng with Section 70(NI) fFivision 3oflhe Business and Professions Coda)) SWIMMING POOL ELECTRIC VALUATION
W^y othat hei3excmpuhemfmmand the basis fonhedleged exemption.Aryl violation of OUTLETS-SWITCHES-FIXTURES
�4 So, m703156y anynpplicollar, apermil subjems the upplicannnacivil penalty of
n01 more Den Eva hundred dollen
W_O NEW RFSIDf?NTIAL EI.ECIR S PT.
o ❑ I,asow,k,.rhepmpHartatmo,myememad arferegesasthei(sole compensation, Q' STORMS 'TYPE CONSTRUCTION
Wipe will dvthewons andthe he Cm0isnmi License Law dosnotale(Slytoan Business
and Profiesscanywhobu Curb: COmmcton,License law i not apply lf an owner of
is
propcnywhces,proorimpravesth impoandwhodressochw0rkh off art thmughhia
cmplayeesproigor improvement is vementsare not iearmdoroffered thHoamay- 'OCG GROUP RES.UNITS
huweveq the ave the bur en ofpvin is sold s,di in of build or comm a for t ur mass f TOTAL:
builder will have the harden of proving then he did not build or improve for purp0x of
sale) Z gJ� Y .
❑ les owner0f the pmpeny vn exclusivelycnnaomingw lhhcensed comment i QrY.qAg- !c)rr4Rl,UF1 GPERMI s. A?'JERx FLOODLONE APN
construct te hproject(Sec.70f4,Business end Profexions CWa;)The Contracm's PERMIT ISSUE E
License Law fres notapply loan ownerofpmpeny who buildsorimprovesiberenn,and
who contracts forsuch projects with a Hammonds)licensed pursuant to the Contractor's gLTiR-D N&VENT-WATER FEE SUMMARY
License Law. (HA)
❑ 1 mm enempt under Sec. ,B&P C for This rcawn BAC AW PROTECT.DEVICE IIT51 FE'
Own
SANITARY YN
tt Uva RAINS-FLOOR,ROOF.ARPA,CONU., NIeCE1PfM
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
1 herehy elft that I M1ave n eenifcmm of cnnsum 1°xlf-Insure,or a cerlilimate RrCEIPf is
FIXTUNFS-PI?ft TRAP
mk 'C°mpensvionlnsurenceoracenift co Hereof See.38W.labC ich PARK FEE Y N
era all empinya's under this permit.l/Y GAS-E RECEIPT N
PolicyN W PA. OUTLE BUILDING DIVISION ILLS
Company GAS- .SYS' 6(PID PLANCHECK FEE
❑ Cenifie l copy is hereby furnished.
❑ Clarified copy is fled with the city inspemio°division. GRt S N R WASTE ,RcEPPOR GRADING PEE
CERTIFICATE OF P.KEMPI'ION FROM WORKERS' GREASE A SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one hundred dollars I$ ) SEWER-SANYTARY-STORM FA. PT. ENERGY IEE
or less.)
I cenify lhmt in the perforanceof the Work her which this permit is issued,lsha WATER HFATER W/VENT/LL
not employ any parson any m as
s o to become subjectorkm the Wer' PAID
,z Compensation Lawsof Califomiu. Data WATER SYSTEM/IREAT Data ReceiptN
Applicant
Z 0 NOTICE TO APPLICANT:If,after making this Campeau,of Exemption,you should NEW RESIDENTIAL ,MIL SQ.PI'. TOTAL:
HC/) become subicalmme Workers Comommumn Provisions of the Lahr Cade,you must
jforthwith comply with such provisions or this permit shall be deemed rev°ked. 1. X BUILDING FEE
z CONSTRUCTION LENDING AGENCY SEISMIC FEE
hcrehyuffirmthauhe.iso construction kedingagency far the pert..Hof TOTAL:
V Q thework for which this permit is issued(See 3097,Civ,CJ ELECT RIC FEE
F
Lenders Name PLUMBING PEE
w0 Lenders Address
rnQTLY , 4"MECFIANICAL PIiRMI'f t EEE.
L) I ctfy that 1 have read this appliamion and slate that the above information is ' -
7" correct. l agree to comply with all city and county undinsrices and state laws reining in PERMIT ISSUANCE MECHANICAL FEE
ON
E" building construction,and hereby authorise represenmtivesoflhiscily to enter upon the
U 'Z above-mentioned propcny for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree 1°save,indemnify and keep,hartrsa the City of Cupcninu against
Iiabililies,judgmems,costs and expenses which may in My way accrue against said City AIR HANDLING UNIT(TO I0,000 CFM)
in cansvauence of the grunting or this peril.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Applicam/Csmrmor Data EXHAUST HOOD(WMUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE. HEATING UNIT(TO 100.0(1 BTU) Data Receipt N'
Will the applicant no future building occupant sure or handle hazardous material I(EATING UNIT(OVER I W.0100 BTU) TOTAL:
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Semi an 25532(a)7
11 Yce No EEVENTILATION FAN(SINGLE RD) Nay
Will theupplicam or Tenure buildingaccupmm uxequipmemor Devices whichemil
BOILER-COMP(3HP OR H0.0130 BTU) ISSUANCE DAT
hazardous aiI corroommnls as defined by the Buy Ares Air Quality Manngcmcnt BOILER-COMP(OVER 100,000 BTU)
❑yes fNo NEW RESfDENT1A1,MECH.-1Q.If, r �
I have read the humaallous materials requirements under Chapter 6.95 of the MAR
California Heahh&Sakty Code,Secl. arm5o5,25533 and ospon4. 1 tydemand then m 27 �n
if Cthe building Helloes Safety
ntly haves tenant,5, itis myd 25534, ilunt0amity the J
a 0, of the oxpm firhich must be 1 or 1°issumc of n nifarri of
c Pnr. City U
` C\IV0 ' '
Ow ed Parc T I ISSUED BY:
OFFICE