26876 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
ADIEISIRL'-6T.ECIRIZAI. PERMITNO.
CITY OF CUPERTINO APPLICATION/PERMIT PLUMBING-MECHANICAL 26876
BUILDING DIVISION BUILDING PROJECT]DEN'I'[FICA'I ION
BUILDING ADDRESS: SANGARYNO. APPWCA'DON SUBMITI'ALDATH
god B"0 eve lame- U wfo CIOdTa
OWNERS NAME: w PHONE: CONTRA OR'S NAME: LIC NO: NIC CONTROLN
grit der 3 —226 C�A-FT 6 � e
ARCHIIUCTITOINEER: LIC NO: ADDRESS:
i ds B2 IIJ)b 0-4 cf S,Yelf- 9sia
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEF-
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
JOB DESCRIPTION
GCZ IhembyafliemthatTamlicenredunderprovisimsofChapter9(cammmeingwith
[1300 Sccfion T000)of Divisim3ofthe Businesswd Pmfemiom Co ,mdmylicenuuin PANELS
Mfull force and effect. �y..,
1--ZW
License Cl s Lic.p 4 - n UP T02(O AMPS L
m 7y Date �' Contrmtor / / OVER
-IM AMPS SQ.FT.FLOOR AREA $`SQ.FT.
ZFNZ Rhall he CTSDECLARATION OVER IOOIIAMPS
CZ-0
I understand my plans shall be used us public records.
W SIGNS ELECTRICAL
�WLicenxJ Professional
sass"'' OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MIg
.�Oa V I hereby M.that 1 am exempt from the Conuactmis License law,for the
W 3 p.rFjr following mown.(Section 9031.5,Business and Professions Code:Any city or county TEMP.METER OR POI INS _ —
0 which myuires a permit to construct,ober,improve,dematiah,ur rtpaa anY smu<ture POWER DEVICES v J
2C!! 7 famem its issumce.alaarequirca theapplicant for such Permit to file a signed statement
,% <0 @mheislicemed,mannummeprovisinna of the Comracmis License Low(Chapter SWIMMING POOL ELE IC
o.ao� 9(commencing with Section 7W)of Division 3 ofthe Business and Profession Code) VALUATION
^,n or that he is exempt therefrom and the basis for the alleged exemption.Any situational
^ OUTLETS-SWITCHES- %TUBE
=O Z Q Section 9031.5 by any applicant fora permit subjects the amm
pplict a civil penalty of
not re mothan Eve hundred dollars($500).
f. .
�� ❑ hmownero(thepwpeny.ormyemployms withwegesustheirwlecompensmNEW RMIDPAL ELEJCR ion. 5 Q FT. STORIES TYPECONSTRUCTION
d willdo the work,andthe srecture is not intended oroffered forsole(Sec.JU44,Business
and Profs ions Code:The Comment Limrue Law does not apply to an owner of
propeny who builds or improves thereon,and who does such work himselfar through his OCC.GROUP RES.UNITS
ownemployees.provided that such improvementsamnot intendeloroffered forsale.If,
however.t ebuildingorimpmvemcntiswldwithinoneyc ofmmplefion,theowmr- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
tea')' QTY. PLUMBING PERMIT FEE WOOD_ZONE pPN
❑ I,mawnerofthepropeny,amexclusivelyconmactingwithlimnacdcanmmtorslo
omtmet the project(Sec.9044,Business and Professions Cale:)The Contractor'spERMI'T ISSUANCE
Limnw Lew does oat apply to m owner of progeny who bui Ids m impmve thermn,and
who contracts for such projecis with a contractors)licensed promanuo me Contractors ALTER-DRAIN de VENT-WATER(IA) ITESUMMARY
Licence Law.
❑ 1 am exempt under Sac. ,B h P C for Nis reason BACK FLOW PROTECT.DEVICE OUTSIDE FEE
SANITARY Y N_
Owner Dam DRAINS-FLOOR,ROOF,AREA.COND. RECEIPI'N
.
coven WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑Workers
Co penrmion Ins ve acmincmeofconw themid6ce.38 o,acmificem of FIXTURES-PER TRAP �' RI?CEIPI'M
Wmnalle ployee'iunlm this Permit. nod copy thereof(Sec.3800,Lab CJwhich PARK FIiE Y N
ars ell employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT N
Policy p BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASPANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section rumdrim bcompincd ifthe permit is house hundred doll.($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEF.
orlcss.)
I certify that in the performance of the work for which this permit is issued,l shall WATER GRATER WNENTELECTR
nor employ any person in my manner w to bac me s ben to the Workers PAID
Cimpcnadion Lu sof Cel( Dam WATER SYSTEMfrRHATNG Dam Rercifm0
Z Applicant$ � IuZ
should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
Z rA NOTICE TO ct to me Workers Compenter sation
this Certificate o of Labor Cod,you
fry become wbjen to the Workers Compenmhan provisions of the Labor Code,you must
forthwith comply with such provisions or this permit shall be domed revoked. BUILDING FEE
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirn that there is a construction lending agency for the performance of L
V O the work for which W s permit is issued(Sec.309],Civ.C.) ELECTRIC FEE
Lender's Name PLUMBING FEE
O Lender's Address QTY. MECHANICAL PERMIT FEE
1 miff,that 1 have read this application mit sate thus the above information is MECHANICAL FEE
.�"' FC7 correct. lagreemcomply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
F' buildingcommucdon,andhcmbyauthornm rexnmtivaafthiscit Wcnterupmthe CONSTRUCTION TAX
L) 7-. shove-mentioned pmNny for inspection purpows. ALTER OR ADD TO MECH.
I agree to save,in 'fy and keep hamdess the City of Cupertino against
li bilinex.judgm tests hichmnyinan ayaccnreag' said City AIR HANDLING UNIT TO MI S0 CPM)
I Consequent f cm AIR HANDLING UNIT(OVER 10,000 CPM)
C
ignature R ApplieanVCan Datc EXHAUST HOOD(W/DUCq
PAID
HAZAR US MATERIALS DISCLOSURE HEATING UNIT(TO ITIL,000 BTU) Dam Receipt IT
Will the applicant or future building occupant store or handle harardous materialBEATING UNIT(OVER 100,1100 BTU) TOTAL:
as defined by the Cupertino Municipal Cade.Chapter 9.12,and the HW th and Safety
Cade,Section 25532nd? a/ VENTILATION PAN(SINGLE RBSID) P Me
❑Yes ➢�4"v'o
ISSUANCE DATE
mm
Will theapplietfumte building occupant maequipment ordem
evices which it BOILER-COMP(3HPOR 100,000 BT) (I
hamrdous air contaminants as defined by the Bay Ams Air Quality Management BOILER-COMP(OVER 100,000 BTU) 171994
• ❑
District? /s L
Yes 0 N NEW RESIDENTIAL MECH. SQ.IT. t+II/ (Jf- LurCN��
I have rend the harsNms materials requirements under Chapter 6.95 of The n/v
Califomia Health a Safety Code,Sections 25505,25533 and 25534. I understand that
if the building does not currently have a moon,thus it is my responsibility to notify Ne
occupant of the ouTu amens which most ba met prim to issuance of a Certifime of
(xtupmey.
Owner m suthodsd agent Data TOTAL: ISSUED BY:
OF