26777 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B1-11,11tol.-ELEi,"rRICAi, PHRMITNO.
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING-MECHANICAI, 26777
BUILDING PROJECT IDENTIFICATION
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IIAING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATIi
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athero L11 N
NHRSNAMH: ( nn PHONE.: C p
NTRACTOR'SNAM�Ear \^ LK:NO:
0 S "O(Z N E L S'1^ ' \ \ ��V N/C CONTROL.
•ARC]IITECTkiNGINEti1C LIC NO: A URS
atuq KI,f �.
CONTACT: PHONE: °"•d acts ) BUILDING PERMIT INFO
QTY.,.P.So- kLP''fRICP�RMIXT-0 T ,FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL �r
OzZ Ihembyaffnm that l atm licensed underprovidirmix'Chapter 9(cnmmencing with J
�UOOp Seaion]IXp)of Oivisimn3of the Business end Professions Code.and myliurtu is in PANELS
<VU License xClass Class fact.
<F Z,µI fallfLic.N IIP T0200 AMPS
to<y Date Contractor 201-1000 AMPS
Fyz ARCHITECTS DECLARATION OV
CR 1000 AMPS SQ.FT.FLOOR AREA $/SQ.PT.
OZ 1 understand my plans shall be used as public records.
F uo�pW J SIGNS ELECTRICAL
6y , Licensed Prufkssional
ise< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
x0.0c. 1 hereby affirm that 1 am exempt from the Conaaemrs License law for the
W 34q¢ reqfollowing reason.(Section 7032.5,BusirmoturlPtnfessions CWs:Aayciryorcounty TEMP.METER OR POLE INST.
F p1 C'J which uires w a p.it construct,site,,improve,demolish,m repair any sticture
War prior wits issuance,also requires the applicant for such permit to rile a signed statement POWER DEVICES
< That he is licensed pursuant to the provisions of the Contractor's license Law(Chapter SWIMMING POOL ELECTRIC 0.0.0 9(commencing with Section 7")of Division 3 of the Business and Professions Code) VALUATION
y' _o, or that he is exempt herefrom and the basis for the alleged exemption.Any violation of w�
F.z,Y Section]031.5 by any applicant for apermit subjects the epplicvmnoecivil penalryof 0 �S S,q, 11,
C not more than five hundred dollars($500). ND• RESID ACS EI. S .FT.
C� ❑ I,asowneroHhepmo ny,ormyemploymswithwagesastheirsolecompemation, - r- Q STORIES TYPE CONSTRUCTION
willdo the work,and the svucwre is not intendedoroffered for sale(S<cA044,Bminess ` 1 .I
and Professions Code:The Contractor's License Law does not apply to an owner of �•J 6 I
papery,whobuildsor improves therkomand who does such work Iimsclforthrough his OCG GROUP NIiS.UNITS
tin employees,provided that such impavemenN urenotinrended onsffered forsale.If,
however.the building or improvement is sold within one yearofcompletion,the owner-
budder will have the burden of proving that he did not build or improve for purpose of
cale
)Lasownerofthe property,am emwsivelyaontracting with llcenated examines m " PLUMIiING PERMIT � .FEE. FLOOD ZON MN
❑
construct the patent(See.7014,Business and Professions Cade:)The Contractors
License Law dmsnot apply aanownerofpropeny whobuildsorindomesthereon,and PERMIT ISSUANCE
who contracts for such lrrojects with acomramm(s)licensed pursuant o the Contraawrs ALTER (LA) ;,s'Tt
License Law. FEE SUMMARY -
❑ I nm exempt under Sec. B ffi P C for tie mason BACK FLOW PROTECT.DEVICE OUTS FEE
SANITARY Y
Owner Da¢ RECEIV
• cn DRAINS-FLOOR,ROOh,AREA,CONO.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ 1 hereby enc Conaffimt Natlhave
rance oni0cate ofconaard thereo(Sec,re,or Lab C.)atte ofwhich FI%TURES-PER TRAP RECEIPI'p
Workers'Compemminn Insurance oracmifiedenpy thereof(Sec.3800.Lab C.)which DANK FEE YN
rs all employei a work,this permit' GAS-EA.SYSTEM-I INC. OUTLETS RECEIPT N
Policy N BUILDING DIVISION FEES
Company GAS-EA.SYSTHM-OVER 4(EA) PIANCHECK hili
❑ Certified copy is hereby fumished.
❑ Certified copy is filed wit the airy inspection division. GRFASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKFAS' GREASE TRAP
SOILS FEE
COMPENSATION INSURANCE
(This section need not bemmpleted ifthe permit is fmane hundred dollars E1100) SEWER-SANITARY-STORM EA,200FT. ENERGY FEE
or less.)
I certify that in the perf.mnnceoffor work for which tis permit is issued,i shall WATER HEATER WNENT/1?I.ECTR
not employ any perawn in any mother so es an become subject ,,the Work. PAID
Z Cnmpenslionlswsof mi
Califos. Date WATER SYSTEM/TREATING pate ReceiptN
Applicant
ZQ NOTICE TO APPLICANT:If,after making this Certificate o'Exemption,you should NEW RESIDENTIAL PLMB. SQ.Fr. TOTAL:
FU) become subjmno the Worker's Compensation provisions of the labor Code,you must
1 forthwith comply wit such provisions onhis permit shall be dmmed rtvnked. BUILDING FEE 6f �a
LkI A CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affimt that There is a construction lending agency for the perfomunm of TOTAL ELECTRIC Mr,
tbn work for which This permit is issued(Site3097,Co,C)
landers Name d '$ " 's PLUMBING E
O F Landers Address QaX; M[CIJANICAL PERMIT FEE,
HE
I certify than I have read Nte t
is application and staat the above information
F irce".Iagrcetocomplywithallcityandcoomy ardiaunces end sate laws return, PERMITISSUANCE MECHANICAL FEE
F" � building nonaction,and hereby authodae repmsentatives ofthisciry toemer upon the CONSTRUCTION TAX
U � uhove-mentioned propcny for inspection purposes. ALTHRORADDTOMECH.
(We)agree a rove,indemnify and keep himtless the City of Cupertino against
Iiabilities,judgmenD,costs ad expenses which may in any way it.mengainst said City A IN I IANDLING ON IT IT 010,000 CFM)
consequence of a granting of thi permit.
AIR HANDLING UNIT(OVER 10,000 CFM) \
P 41s" 0.S-ra S
mgawm of Ap licant/Contrad Date EXHAUSTHOOD(W/DUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date ReceiptN
Will the applicant or future building occupant stare or handle hazardous material HEATING UNIT(OVER Ifq,000 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the health and Safety
Cale.Section 25532(a)9
❑ycx ❑No VENTILATION FAN(SINGLE RESID)
BOILER'-COMPDHPOR 100,0011 BTU) ISSUANCE DATE
Wus it 011kamorfuwre building by the.Bay A ipmcn Quality
es Management P A 9 Y./
huzallous air contaminants n defined by the Bay Area Air Quality Management BOILER-COMP(OVEN IW,000 BTI,,
1 DisWct?
r ❑Yes ❑No NEW RESIDENTIAL MECH. SQ,FT. JUL 201994
1 have rid the h ti Mous materials wtrimmems under Chapter 6.95 of the 1994
California Health&Safety Code.Sections 25505,25533 and 25534. 1 understand that
if the building does not currently have a team,that it is my responsibility to notify the CITY U/- V VY
occupant of the requir mens which must be mer prior to issuance of a Ccnifieste of tel I I�
Occupancy. e
Ownerorauthorized agent Data 'IOTAI ISSUED Bsa—aag�Y.
OFFIC