26555APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINOUILD
APPLICATION/PERMIT PLUMBING - MECHANICAL.
BUILDING DIVISION BUILDING PROJRCT IDENTIFICATION
PERMIT NO,
�i GN C C C
G v J J J
DING ADDRESS:
SANUARYNO,
APPPLICATIONSUBMITI'ALDA'M
I OSlB C UNIT Is LOT#
�C+
OWNERS NAME, PHONE:
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CONTRACTOR'S NAME: LIC NO:
N/C
CONTROL#
ARCIIITF:C'f/ENGINEER: - LIC NO.
A KESS:
L. 6
t ✓p
coNTAcr: Pxorve:
QTY. ELECI'RICPHRMIT FEE
BUILDING PERMIT INFO
PLu_ MB MECH
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'•
PERMIT ISSUANCE ►'•
LICENSED CONTRACTOR 'SDECLARATION
thereby isionsof (co mmencing wird
thatI amlicensedinto
APPLIANCES - RESIDENTIAL
- JOB DESCRIPTION
PANELS
of i
a Coer9
Section 7d0I) of Division 3 of the Business and Professions Code, and my llcemse Is in
rand
fill force and effect �q �#
Licen ¢Class Lic.# 'Y/ `�yK
UP TO 200 AMPS
/�
201- 1000 AMPS hill
Du- Contmcior'
ARCHITECTS DECLARATION
1 understand plans shall he mad as public recoMs.
IL�i#
OVER 1000 AMPS
SQ. ET. FL OR AREA /$$//SQ. FT.
SIGNS ELECTRICAL
ed
Licensed Pm(eselmnel
OWNER -BUILDER
rcDECLARATION
I hereby affirm tihoton 1 am exempt Fourche Contractors License Lew for the
SPECIAL CIRCUIT/MI
following reason (Section 703L5, Pm&salons Coda: Any pity or county
TEMP. ME'IBR OR E T.
ITL 1
r, of e,, land
which requires n permit to cmastm a poli improve, demolish, fi repair any stmcturo
ch fileese
its icenancc,armara tires Neapplme,
-
POWER DEVICES
of the CopeamiRo
,bar he Lava
9(comisncing ,in cti t70 proDivision the GmGnclors License Lew (Chapter
9(oommeneing with Section7W0)of Divisinn3nf the Business and Professions Code)
SWIMMINGPOOLELECTRIC
W
,,,that he i, exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant m e civil penalty of
/�VA(yr�UA
��"k
D
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Q
LETS - SWITCHES - FIXTURES
not more than live hundred dollars($500).
❑ I,nsmwn,rofNeprmpetty,ormyemployeeswi0wagesastheirsolecompcnsation,
NEW RESIDENTIAL ELECTR SQ. FT.
STORIES
TYPE CONSTRUCTION
will do the work, and do, sourn is not lnumbumroffered mature (Set, Business
and Professions Cade: The Contractors License Law does not apply m an owner of
Property whobmldsmimprover thereon, and whodoes such work hirrec ordium,hhis
employees,pmviAW thetsuchimpmvententsarenolintended oroffered fmrsole. If,
�.
i � �O'C.�ROi P_� i
.UNI 5
L, -v
mveoenlisse, he dilnoneycar of improve for theowner-
builder will have the harden o[prmving that he did not bund or improve for purpose o[
build.,willhav the burden
QTY, ',' PLUMBING PERMIT FEE
,:tied.
E]I.inins erofthepropeny,amexclusively,momictiagwithlicenseiembercmmm
construct the project (Seo. 9044, Business and Professions Cafe) The Continuities
License Lowdoesmtapplytoaaownerofproperly wholmildsmrimpowes thereonand
FLOOD'
TE g Iq
APN
PERMIT ISSUANCE ,
73—
who contracts mrsuch projects with acmntractuo(s) licensed pnmuant to the Contractors
License law.
ALTFR- DRAINffi VP.NT- WATER (PA)
FEE SUMMARY
❑ I am exempt under Sec. , B & P C for this reason
BACK FLOW PROTECT. DEVICE
- OUTSIDE FEES
SANITARY Y N
RECEIPT#
Owner Date
DRAINS- Ell ROOF, AREA, COND.
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX Y N
❑ thereby affirm l have acmntm lfi,meofconsoself-Insure,am
mth mcemimaof
Wmomi Comperemlma Insurance me cettlfedcopythereof(Sen. 3800, Lab C.) which
RECEIPT '
PIXTURES - PER TRAP ��
PARK FEE Y N
GAS -EA. SYSTEM -1 INC.INC40UTLB1'S
rs all empin ee's under this croil.ECEI
y F
Pnliay#
#
BUILDING DIVISILN FOES
PLANCHBCK FEE
Company
❑ Certified copy is hereby fumished.
GAS - EA. SYSTEM OVER 4 EA)
GRFASE/INDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA, 200FT.
ENERGY
•(This section need not be completed ifthe permit is fommehumbeed dollars ($100)
or less.)
WATER HEATER W/VENT/ELECTR
l certify thmin Ne performance of the work for which this permit is iasued,ISM1aII
t employ any person any manner so to to become suhiecl m the Workers'
PAID
WATER SYSTEM/CREATING
C mp,neatloo Laws of California. hate
I ate Rewipt#
pp". ii/ / Ami .
NOTICETOA ICANT:If, aftermaking this Certificate of Exemption,you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
bject to the Worker's Compensation provisions of the Labor Cade, you must
mrthwithsucomply with such provisions or this permit shell be deemed revoked.
BUILDING FEE -4
SEISMIC FEE Wo
CONSTRUC 70N LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3099, Co. G)
Qcff—
ELECTRIC FF.E f
Lendcts Name
-
QTY. MECHANICAL PERMIT FEE
PLUMBING FILE
Lenders Address
I certify that 1 have read this application and some that Ne above information is
erect. Iagree m comply with all city and county ordinances and sate laws relating to
PERMIT ISSUANCE
MECHANICAL FE .
buildingrnnswnion, and hereby arithmetic representatives ofthis city to enter upon the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECH,
Lf
CONSTRUCTION fAx
(We) agmo to save, indemnify and keep harmless the City of Cupertino against
limbilities,judgment,.ends nnd,s,e,. which may many way recon, against said CityAIR
HANDLING UNIT(TO 10,000 CPM)
in consequence of te hgounting of this permit
T
AIR HANDLING UNIT (OVER 10,000 CFM)
Signature ml Appbcan ontracmr Date
EXHAUST HOOD (W/DUCT)
PAID
HEATING UNIT (TO 100,000 BTU) '
HAZARDOUS MATERIALS DISCLOSURE
Dam Receipl R
HEATIND UNIT (OVER IW,000 BTU)
Will the applicant or future building occupant store or handle heaerdoes material
as dmOced by the Cupertino Municipal Cade, Chapter 9.12, and the Health and Safety
VENTILATION FAN (SINGLE RESID) 0
Crile, Section 25532(a)'I
❑ Yes ❑ No
BOILER - COMP (3HP OR 100,000 BTU)'
I SUANAgl Dir T.B
P.l9 � {/
Will the npplicun[orfuwm huilrl,ingoccupamueeequipmunardevioeswhich emit
BOILER - COMP(O PIER 100.000 BTU).
i, hazardous air contaminants Is defined by the Bay Area Air Quality Management
/ Dinlrict't
❑ Yes ❑ No
A
1Q9,4
v
�U� 141994
NEW RESIDENTIAL MECH. SQ. FT.
I have rend the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505,25533 and 25534. l understand that
now building does not currently have tenant that it is my responsibility to notify the
CITY (fir 4VECn IIIYU
occupant of the requirements which mum be met prior to Issuance of s Certificate of
'
Ocatpuney.
ISSUED BY:
Owner or authorized agent - Date
TOt'A
OFFICE