26501 Arrut;ANT IU FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
DIEDIfi PERMIT NO.
C Y OF CUPERTINO APPLICATION/PERMIT PLUMBING-MECHANICAL
26501
a�nuaDlNc DIVISION
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. AIRMIIICCATIONSUBMMILkA'D�ATE
\ UNIT# LOTH
OWNERS NA i PHO CO CfOR' NAME: LIC NO'.
Z iner N/C CONTROL#
ARCIIITECT/E GTNEIiR: CNG: I� E �a
CONTACT: PHONE: A 484357P
v BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
� BLDG ELECT PLUMB MECH
PERMIT ISSUANCE Ik71
LICENSED CONTRACTOR'S DECLA TION• APPLIANCES-RESIDENTIAL Al 10B DESCRIPTION
y.Z I herebyaffirmthm l am licenseiundeprovisions nfChapter9(commencingwide I
00C
PANELS
Sectinn]OW)af Diviaion3gl the Business and Professions Codd,end mylicense is in
fullmc and effect.12
Q W Licensefoass LIC.# UPT0200AMPS
NF.<,o• Dam Contrcrm 201-1000 AMPS _
ZOr�Z •"rl CHITECTS DECL OVER 1000 AMPS r SQ.FT.FLOOR ARBA 5/SQ.FT.
oz—O y..t .I un rstend my plans shall be used as public reconds. L_ ® ��
j�q�d :1 Licensed Professional SIGNS ELECTRICAL ��ss��•• p�
S go56 OWNER-BUILDER DECLARATION \' SPECIAL CIRCUDUMISC. I �� II II p
�sd
OWL) 1 hereby affirm Thal 1 mn exempt from the Convector's License Law for the 11�/Y E i
W 3 u tia fallowing reason.(Section 703 1.5,Business and Professions Code:My city or county TEMP.METER OR RILE INST.
Fp�j J which requires a permit to construct,aRep improve,demolish,or repair my sanctumDATE
prior to its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES _
yp'�] <o that he is licensed pursuant to she provisions of the Conunebr's License Law(Chapter
4 SWIMMING POOL ELECTRIC
d�o 9 that he is(commencing with Section it
of Division Sof the ed riesrand.Any cane Code) VALUATION
a)'^y or Section lit L5by hcrtfrommd Ne permit subjects
Nets the applicant
Myl Penam of OUTLET'S-SWITCHES-FIXTURES
ZQ Set me than five
Ydred doltfor a rs($50mit subjects the applicantaacivil penalty of V
not more than Eve hundred dollars yS .pl
C r'ZO NEW RESIDENTIAL ELECIR —SQ.FT.
m ❑ Lasowncrlfthe propeny,ormyemployaswiN wegtsartheireolecompcvetion, STORIES TYPF.CONSTRUCI'ION
ana3— willde Ne work,and the swcture is not imcndcdoraffered fmale(Sx.7044,Business
and Professions Code:The Cantmctnrs License Law does not apply w an owner of
Fri who builds or improves dareon.and w he does such wart hinssel f or through his
emloyms.providMNetmchimpmvementsmenminteoe moReredfmale.If. OCC GROUP EIIN
Eve',the building m improvement is sold within one yearofcompletion,theowna- TOTAL:
er will have the burden of proving that he did act build or improve for putpose of
sale.). QTY. PLUMBING PERMIT FEE
❑ I.asownerofthe property,ameaclusively camraciing with licensed contractors in FLOOD ZONE
ommuct the project(Sec.7014,Business and Professions Code:)The Container's
Licence Lawdas nmapplymmawnaofpropeny whobuildsarimprovts thereon.and PERMIT ISSUANCE
whocommns fmsuch projects with a commetm(s)licensed pursuant to the Conuuctols ALTER-GRAIN&VENT-WATER(EA) FEE SUMMARY
Lica;e Law.
❑ I am exempt under Sec ,B&P C for this reason
BACK FLOW PROTECT.DEVICE O ID
SANITARY YN
Owner Dete DRAINS-FLOOR.ROOF,AREA,COND. RECEIPfp
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y
❑ lhernM1y affirm Nmlhave acenificme of cnnsem to self-insurt.oracertificem of FIXTURES-PER TRAP RECEIPT#
Workers'Compensation Insurance or acenified copy Neearf(Sec.3800,Lab C.)which PARKFEE Y_N
crsall employee's under this pemik GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy a BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHF.CK FEE
❑ Certified copy is hereby famished.
❑ Certifial copy is Eled wiN Ne city inepenian division. GREASPANDUSTRL WASTE INTERCEPTOR GRADING FEE
I CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS FEE
/ COMPENSATION INSURANCE
(flus section treed garlic completed ifthe permit is Amore hmdrNdollan(5100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
m mss)
I certify that in the perfomarma.f Ne work for which this permit is issued,l shall WATER)[EATER W/VENT/ELECTR
and employ my pcesan in my manner m bee s jets to the Workers' PAID
Compensation La a fa Dme WATER SYSTEWITREATING Dam Receipt#
O 7-s Applicant
z . NOUCETOAPPLICA T.IL making this Certificate of Exemption,you should NEWRESIDENTIALMMIL SQ.FT. TOTAL:
rr lin become subject to Ne Workers Compensation provisions of Ne Labor Code,you must
Lam^ , forthwith comply wiN such provisions err Wspemit shall be deemed rtvoked. BUILDING FEE 9a+ V
CONSTRUCTION LENDING AGENCY SEISMIC FEE O
I hereby effum that there is a cons mctma lending agency for the performance of
V O the work for which Nis pcmdt is issued(Sec.3091 Civ.C.) TOTAL: ELECTRIC FEE
{{--�-� Lmdcrs Nsave
Lender's Audi QTY. MECIIANICALPERMIT FEE PLUMBING FEE
Q V I certify that I have rad this application and sate then the above infomutim is MECHANICAL FEE
r1' acorrect.l agree to comply with all city and county ordinances and shoe laws relating to PERMIT ISSUANCE
�^ (A building construction,mtherebyeuNodze representatives of Nis city renter upon the CONSTRUCTION TAX
L) 7 above-mentioned property for irrspeaion purports. ALTER ORADDTO MECH.
F7 (We)agree to scop indemnify and keep harmless the City of Cupenim against
Iiabilities,judgmems,costs and expenses which may in my way mere against said City AIR HANDLING UNIT(TO 10,000 CFM)
in consequence of Ne granting of this x,mrit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of AMlicml/Conuoctor Dam EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building oaupont more or handle hautdous matmal
as defined by the Cupenino Municipal Code,Chapar 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 JIM TOTAL:
Cade,Saction 25532(a)? VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
W i II Ne eppl leant or fmurt building cecu pmt use cqu ipmem m devices which emit
BOILER-COMP(SHP OR 100,000 BTU) ISSUA�IC
gcmj us air comvnmts inas defined by the Bay Area Air Quality Management BOILER-COMP(OVER 10,000 BTU)
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. JUN B1'[L1 N 1 O 1vQQtpy
" s
1 have mad the hazardous materials requirements under Chapter 6.95 of the CI I Y Ur
V B I
Califomia Health&Safety Cade,Sections 25505,25533 sand 25!04.I undersand that
if On building doe not curtenlI havenremmt,th 1itis my responsibit Iy to noIf y Ne
cupwrt f the req 'mmc hs ich m t h mo n m issuance of Ceni et of
Occu y.mar
Owns r ur o get ate TOTAL: ISSUED BY: e' /��/•�
OFFICE