26373 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPF,RTINO - 'ExEoO-.1.�,RrtA, PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 26373
BUILDING DIVISION BUILDING PROJECT IDENT'IFICA'TION
BUILDIN r(AD�)DRi)Ii.5�5: SANITARY NO. APPLICATIONSUBMITI'ALDKEE
V J LOT
NPHpONE.: CONTRACTOR'S NAME: LIC NO:
P,
NIC CONTROII#
ARC TECT ENGINEER: LIC NO: ADD SS: ❑
TOS
CONTACT': PHONE:' i gse ,;wg.�r 8-i�.rJ' :d> S " ' �,
QFP 2 ELECTRICPLRMIT;rjl 1 FPP�-1 �' 'a' HULL"DI'NG PERMI7YINF0 s`
D. ] t!Y€a7.aWP Yr eyg c`s•w 5 $: Y.
ELECT PLUMB MECH
PERMIT ISSUANCE El ❑ ElLICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL
QWz I hereby affirm hat l am licensed under provisiensof0hader9(commencingwitit
bE Sxtion?andefDivision 3 o the Nosiness and Professions Code.and my license is in PANELS
ss'� Licemreeants effect.
FZty Lirertse Class Lic.p UP T0200 AMPS
6 y Da - Counselor 201-1000 AMPS
_Z~'z ARCHITECTS DECLARATION OVER IoOOAMPS SQ.FT.FLOOR AREA W,FT.
OZ-0 tZ-1 I understand my plena shall be used as public records.
y ; SIGNS ELECTRICAL
License)Profeseinnul
<
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
�•��'OyF 1 hereby affirm that I am exempt from the Cosioas Cs License Iso for the
til�r nz-m OJlowi is utesa.Rection 7ommu Business and Professions Code:Any city areeumy TEMP.METER OR POLE INST.
E"W which requires a permit m carman,after,plic improve,demolish,or repair anY structure
primeI,licensed alsontto thsNeapplim,ldtheand for ellCo pcmdtto Licese oadmuccomaLaw(Chapter POWER DEVICES
0. Qp
that he is skins withaction700)of iiiision the Ce Brains License LsiontCrer
aaoo 9(cam heisexemit therefrom
add
Division Sof theed examandptio Profession Code) SWIMMING POOL ELECTRIC VALUATION
g� o Seder h7031.5 by any afmmand the bermitss for bjeasegedexvcant to. civiny l
of
Q Section than
anymoddannfor apcmtir subjects the npplicennoecivil penalty of OUTLGI'S-SWITCHES-FIXTURES
n more then five hundred Rollers($SW).
K I,asowneroOhe n NEW RESIDENTIAL ELECIR
p ❑ Pepe y,nmyemtandeeswithwagnaUhe(Sec.compemation, I'`'� STT TYPE CONSTRUCTION
a 3�
will dmh ssimas and the he Contisnor's License
Law does of apply to
owner of t s I,J u
andpro Professions Code:The Contractor.License Law flees not apply io as owner of ,_,
ownenywhob,provids rimpmvnthereagaadwho deeant imendkMmselfm thmaghhi, / / -� 7
employees,pingor improvement
provement is vemarthinne imstrofsoroffcm.formic,B, `_' s. J J ;,.H R RI:S.UNI'LS
however,ihbulJ g handed
otemenussot he didoneyeu o improve fn Neowner.
builder will h theburden of proving that he did not build m improve for puryou of T 1- Z
sale.).
' ❑
=*PGUaM
EINO3PER_ . Nti _f, APNjI u:ow eroftheproperny amexalusivel contracting contrecnorsto PTY"
smart the project
(Sec.7034,Business and Professions Code:)The Convector's
License Lawdoesnm apply loan owncrofiampenywhobuildsorimprovez thereon,and PERMIT ISSUANCE
who contracts forsuch projects with a csmtracmr(a)licensed pursuan lothe Contractors
License law. ALTER-DRAIN&VENT-WATER ) FEE SUMMARY
❑ 1 am exempt under Sec. B&P C for Nis reason OUTSIDE IDE F•ES
BACK FLOW PROTECT.DEVICE SANITARY Y N
Owner Date DRAINS-FT.GOR.ROOF,AREA,CONS. RCCEIPTg
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y_N
❑ Iherchy aSms that l have a cerifcate ofemosenno self-insore,ora certificate of FIX9'USES-PER TRAP RECEIFFp
WorkersCompensation Insurance or a certified enpy thereof(Sec,31100,Lab C.)which PARK FCB Y N
covers all employee's under this permitGAS-EA.SYSTEM-1 INC.4011'1'LETS
ComRECEIPTa
Puts,N BUILDING DIVISION
Company
Certifiedcopy is hereby famished. GAS-FA.SYSTEM-OVER 4(G) PLANCHECK FEE
❑
❑ Certified copy is filed with the city inspection division. GRIASE/INDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEC
COMPENSATION INSURANCE
(This section needam becompleted if Ne permit is for one hundreddollars(SI00) SEWER-SANITARY-STORM EA.200FT. ENERGY IEE
or less)
T tend,Nat in the performance of he work for which this permis is issued,Ishall WATER HEATER W/VENT/CLCCTR 417
not employ any person in any manner so as to become subject to the Workers' PAID
Compenaeionlawsof California Due WAFER SYSTEM/IREATING Recciptg
Q z Applicant
z 0 NOTICE TO APPLICANT:If..het making Nis Cenificateof Hasmillmd,youshouW NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
V), become sabjectro the Woher's Competermon provisions of Ne labor Cade,you must
forthwith comply war such Provisions or this permit shall be demand revoked. BU Ils'IEE
CONSTRUCIION LENDING AGENCY SEISMIC FEE
=l z Ihereby affirm Ne Net,is a construction lending agency for Ne perfomunm of TOTAL ELECTRIC FEE
L) O the work for which this permit is issued(Sec.3197,Civ.CJ
rr Lenders Name sr pss, AAI � " --F r �' '
F' Lender's Add. QTYp MECHANICAL PERMIT?' '.� ,� ;F,EEPLUMBING FE
' ',='
0 U 1 ,t rify that I have read this application and sate that the above information #t " ."'a*"'"&j4"' A 4 a " j'�Aof
r�" W correct. l agrm to comply with all city and county ordinances and tine laws relating to PERMITISSUANCE MECHANICAL E
F-' y .building construction,endhereby authorize representatives ofthiscity matter upon the GONSTRHGTI NTAX
L) 7 above-mentioned property for inspxtiml purposes. ALTER OR ADD TO MECIi.
G7
(We)agree m save,inJenmify and kmp It dart I the City of Cupertino againan
liabilities.
eco ca.of,' gments,ce and ex ens rhichmay' mywayacentuagainstsaid City AIR HANDLING UNITOO Io,000CFT5)
Nt.i V c I AIR HANDLING UNIT(OVER 10,01)CFM)
omrc fApplicalt/Namwor EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO Ifid"BTU) JD. R Win It
Will the applicant or future building occupent store or handle hazardous material HEATING UNIT(OVER UNLIKE)BTU) TA :
as defined by the Cupedi ae Municipal Curie,Chapter 9.12,and the Health and Safety
Craft,Section 25332(0?
❑Yes ❑No VENTILATION FAN(SINGLE RESID)
Will theapplicannor future buildingoc<upant uuequipmem ordevicea whichemit
BOILER-COMP(311P OR 180,000 BTU) ISSUANCE DATE
hazardous air commonsom us defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District?
❑Yes ❑No NEW RFSIDENTW,MECH.—SQ,E-L
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Cede.Sections 25505,25533 and 25534.I understand Nat /w
if the building does not currently have a tenant that it is my responsibility a notify the I-'41
ecnpsnt of the requirements which must be met prior to Issuance of a Cenifnle ad
Occupancy. V /
Owner or nmhnnzed ogee pate TOTAL: ISSUEDOFFICE
C41�Ur
Ch/Yore.