26051 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - PLUMBING cD7 PERMITTED.
DIVISION APPLICATION/PRMIT -MECHANICAL
fa' exa, BUILDING PROJECT IDENTIFICATION
26051 OJ1
BUILDING ADDRESS: / _ -" �- SANITARY NO. APPLICATION SUBMITTAL DATE
E Lam/ UNIT M LOT#
OWNERS NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
SONES MASON 9 35 NIC • CON RO
•ARCHITECT/ENGINEER: LIC NO: ADDRESS: ` • ❑
CONTACT: PHONE - I --
QTY ' 84�ECf 11C PERMIT IEE `sea UL � BUILDINGiP6 PLUMB FO-MECH
('Q6� TONES ��J377-y3/� � i BLOT PLUME MECH
PERMIT ISSUANCE "
LICENSED CONTRACTORS DECLARATION - APPL4WCES-RESIDENTIAL pp JOB DESCRIPTION
Qmz Ihereby affirmthin Iamlicensed underprovisionsofChapter9(cotreaencingwiN Tl�Piq/re e�/lNjy�s/
00 Section 7")ofDivision 3tithe Business and Professions Code,and mylicemeisin PANELS F;�dF
f 11 forceand eIT II''C
6VzU License Class Lic.ri3174352
UPT02WAMP3 //Mv L,—P.
y¢y DateContractor 201-1000 AMPS
Z FO vv'i Zt-, ARCHITECTS DE co10N OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O'L O I understdnJ my plans shall be used as public Ms. r
pn
'� - II_ . �i; ll.- Flid
9�NLicensed Prof sional SIGNS ELECTRICAL T
WV OWNER-BUILDERDECLARATIONARATION SPECIAL CIRCUIT/MISC.
glO I hereby affirm.ISe that 1 am exempt from the Committees Code:Any city for the FJV
¢130m following reasonerint 1.903L5,Business and
.a,demob Code:Any city arcnumy TEMP.METER OR PO[,E IN
t��; which regnireenpermit re cores the mtegimp rove,demolish,or repair any summer
R'^> prior to its issuance,also re the licant for each vo Neasi signed statement POWER DEVICES
� quires PP Penni g ATE
�'G that he is licensed p Sectio to the provisions of the Comments License Law(Chapter _-, _ -
aXe 9(c0mmeis(commencing pt therefrom
the Division the the Business Any Professions Code) SWIMMING POOL EL --'-- - VALUATION
W,may Seor ctilheiec.5 by anereframnt for a basPermit subjects
thedexlicantn. civil
of OUTLETS-SWITCHES-FIXTURES ( Y'�./Q•
F >' ing more
than five
hundred
dollars
subjects the applicantmecivil penalty of (ll(((
not more than five hundrN dollars($500). NEW RESIDENTIAL ELECTR _SQ.FT. 1
l,asownemfthe o n orm
Itis ❑ pr pe y, yemployed orofw dforrithel(Sec.c0m,Busmen, STORIES TYPE CONSTRUCTION
W will dothe econs and thenode' m Contre ractor's
License
oserdoesn not
9044,Business
and Professions Csparimha Convaceor's License Lew such
not apply m an owner ofproper
costim whobuildsoriedthmmprovesi It improvemectuand nts
is am forihradexi mselfdrthrough his OCC.GROUP RES.UNITS
employees,provi orrimprverreapis sold within one
fiersidtheoonlf, -
budderhowevegillhathe vldingoadenovementissnldedidnoneywrorimpro improve for
purpose f TOTAL:
builder will have the buNen of pricing that he did not build or improve for purpose of
snle) a .wA 11'14,As y a x§;#
❑ I,ns ownerof the Tommy,=exclusively contracting wafer censedcontremnrsm Q PLOMBING PERMITc °4'P FEE} FLOOD ZONE APN
to
ommor he project(Sec.9044,Business and professions Cada,The COnvecmds PERMIT ISSUANCE
License Law d oes not appl y to an ownerof property who bui Ids m improves tberctn,and
wherommecs forsuch projects with a contractras)licensed pursuannoche Comeacras ALTER `L n*
License Law. ti FBE SUMMARY
❑ 1 promoter,under Sea ,B&PC fm this reason BACK FLOW PROTECT.DEVICE OUT'ID•F ES
SANITARY Y N
Owner Date RECEIPT#
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ IM1ercby s[firm thmlhnveacertifieateof toneennn self-Ineurc,0racertlfiratnnf FIXTURES-PER TRAP RECEIPT#
WorkersCompensation lasumnea ora owlfied copy momof(Sce.3800,Lab C.)which PARK FEE Y N
Policy
movepirill empinyap(�rsler!ypealht. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT ri
miff OO✓✓VV//�7 BUILDING DIVISION PEEg
Ctmpwy ��/�6r�1(•l�j r4fZi'�r/ GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certi�py to hereby famished.
'Gf Certified copy is riled with Na city inspection division. GREASMKIDUSTRL WASTE INTERCEPTOR GRADING FEE
/` CERTIFICATE OF EXEMPTION PROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
Masse hin...door he completed ifche permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the perfortsatnceofche work for which thispermlt is issued,I shall WATER HEATER W/VENT/ELECTR
oat employ any Pgrso9l in any,manner an as to become sy�l t Workers - PAID
O Z
Co. �;tion Lyv�pfR.§4lifom glE ,f `-�� WATER SYSTEM/TREATING Date RacelptN
PP I {SL CY�_�
NOTICE TO APPLICANT:IfeF rm ng this Cerificare of Exemption,you should NEW RESIDENTIAL FLAT. SQ.FT. TOTAL:
Hbecame wbjectm Ne Worker's mpensation previsions of to Labor Code,you must
C4 . forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING PEEro
z CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm That there is a construction lending agency for the performance of
U O the work for which this permit is issued Eger.3099,Co.C.) TOTAL: ELECTRIC FEE
Lender's Name gk 5'e d i °y Pp k +k g•y" PLUMBING FEE
u" �+ Lenders Address QTY. 'AMECIIANICAL+�PERMIT 4a FSE
OU 1 certify that I have read this application and stare that the above information is N Y �'L>r��'s�°°''"'��''}�a'4*`e�' RA>a ''r�a
correct I agree to comply with all city and county ordinances and state laws relating t0 PERMIT ISSUANCE MECHANICAL.FEE
building construction,and hereby arborize cormsematives of thiscily wenterupon the CONSTRUCTION TAX
U y above-mentioned propnny for impation purposes. ALTER OR ADD TO MECH.
�i (We)agree to save,indemnify and keep hamtless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way surow almost said Gey AIR HANDLING UNIT(TO 10,000 CFM)
in consequence of the grating of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of ApplimnVConrracmr Date EXHAUST HOOD(W/DUCIU
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building occupant score or handle hazardous material HEATING UNIT(OVER 100,000 BTU) 1 -
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Codon gcrnlon 25532(a)9 VENTILATION FAN(SINGLE RESID)
C3 Yes 11 No
BOILER-COMP(3HP OR 100,000 BTU) fTS$ P�CPa•DATE
Will the applicant or future building occupant a.equipment nr devioeswhichemir e- IJ
• hazardous air conesminanc as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) pflA Ip O
District? „IM i 9
❑Yee ❑No NEW RESIDENTIAL,MECH. SQ,FT. QA
I have read the hazardous materials requirement.under Chapter 6.95 of the v`� /
Calif..is l lemth&Safety Code,Sections 25505,25533 and 25534.1 underetand doer
if the building does not currently have a tenant,that it is my responsibility ro notify the
cupam of the i lauents'InxiMect be met He,to issuance of a Certificate of
Occupancy.
Owner or au 'u ugem am - TOTAL: ISSUED BY:
F'