26128 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
B M.Mr,-I.L.,DUCAL PERMI'TNO.
CITY OF CUPERTINO PLUMBING-MECHANICAL f� a� Q
BUILDING:DIVISION APPLICATION/PERMIT G 1 O
BUILDING Pft(3JF,(:'1'IDENTIFICATION
BUILDINADD S: SANITARY NO. APPLICATTIIONSUBMDTALDATE
1. •C.L'�/ LOT is --2;p1`FO
O E: Pf CON CT R'SNAME: LI O:
' /� NIC CONTROL#
RCHITECT/HN INFER: LICNO: ADORE ,/ �� / ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE El
LICENSED RATION APPLIANCES-RESIDENTIAL
p p4Z Thereby elfmthD emen
talicsedunderprovisions ions Af of ChaDmr9(commencingwith 10B DESCRI ON^^'_
Ri100 Scdiore0ndef Division 3nf the Business trod Professions Code,and mylZ t=ense is in ppNF.ls ,_?at
.
ty [f�' fug Pone end crce(S�a� ''��� p ///'''���
<Zu� License Class��Lie# O O UP T03n0 AMPS
�n=oo Dn Commmm 201.1000 AMPS SQ,FE FLOOR AREA $,SQ.PT.
F'snoe AR Ii1TECTS DECIANATI N
ZOrnK OVER 1000 AMPS /
02^ I unaerstnnA my plans shall he used us public,dards.
h2 j SIGNS ELECTRICAL A L E
Q J Licensed Professional C ors OWNER-BUILDER from
mEC Contractor's
ontra ON SPECIAL CIRCUIT/MISC. f3 /�
O y V I hereby mason.(Se that I am exempt tram the Cimons Co Lien Law for the 1,F/1 P U T E
Say followwhichinguresapermit to 7031.5,Business tens pr Professions Code:or reairAny m orcountyTEMP.METER OR POLE INST. YV�
�'�; which requires n permit m conswct,Ater,improve,demolish,or repair any...ere
Y�
prior to issuance,elsoreyuirts Ne applicant for such#erotica flleesigned summcm POWER DEVICES
GO that he is licensed aramafto the provisions of the Cummctors License Law(Chum.,
L o ' 9(commencing with Section 7")of Division 3 afthe Busineesand Professions Code) SWIMMING POOL ELECTRIC
^y or that he is exempt herefrsm and the basis for the allegedeecmption.Any violation of OIITLEI'S-SWITCHES-FIXTURES
I.ZQ Section 7031.5 by any applicwtfor a Permit Subjects the applieram.civil penalty of
not mom than flue hundred dollars(5500). Q STORIES TYPE CONSTRUCT ION
p NEW RESIDENTIAL.GLECTR S .FT.
❑ Lusowult.unhepmpedy,ormyemvencend withwagesothe(Sce.compete mess
will dothework,wnd the romaireisnorimendedm ow does not
Ser Business
end Professions CNe:The Contmctore Licme law does nm apply w an owner of
property who builds nrimprovntheran,indwhodoeasuchwork himselforthmughhis
own employees,provided that suchimpmvemenlsarenot lenendedorofferedforsale.If,
OCC.GROUP ftF_S,UNITS
however,the buildingor improvement is sold within one year ofcompiction,the owner- TOTAL:
build,,will have the burden of proving that he did not build comments.for purpose of
saleJ'
C] 1,asownerof the property,Sm udmivelyconuacting with licd comtom QTY. PLUMBING PERMIT FEE
ensemcto FLOOD ZONE ATN,
construct the project(Sec.7W,Business and Professions Codc:)'Me Contmmor'spFRMIT ISSUANCE
License Law dad not apply man owner of property who bei Ids m i mpmves thrmen
en, d
whocentrouforsuch Impacts withacontoctiont licensed pareanno the Conwnoh
License Law. ALTER-URAINffi VENT-WATER(EA) FEE SUMMARY
rT
❑ 1 em exempt under Sec. ,B&PC for this mason BACK FLOW PROTECT.DEVICE UTSID
SANITARY Y N
Owner Dam DRAINS-FLOOR,ROOF,AREA,CONE. RECEIPTN
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ I hereby affect that l have a certificate ofconsantoself-inure,macertifcateof FIXTURES-PER TRAP RECEIPT#
orkcti Compensation lnsumnceor acetified copy therad(Sec.3900,Lab C.)which PARK FliE V N
covers ell employee's undct thi9P� RECEIPT#
! 4 GAS-EA.SYSTEM-I INC.4 OUTLETS BUILDING DIVISION MES
X
Companyxi C ^ A GAS-PA.SYSTEM-OVER 4HSA) PLANCIIECK FEF.
C3CeniBed copy a here y famished.
❑ Certified copy is filed with the city inspection division. GREASH(INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed Hie permit is forme hundreddollan(5100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
orless.)
I ratify that in the performance ofthe work for which this permit is issued,)shall WATER HEATER W/VENTELECTR
not employ any person in any matter
s o o to become subject to the Workers PAID
Compensation Lawsof California. DateWATER SYSTEMRRIL ING Date Receipt#
0 z Applicant
z 0 NOTICETO APPLICANT:If,after making this Cetifleateof Excmptian,yau should NEW RESIDENTIAL PI.MB. SQ.FT. TOTAL:
V1 brant,Subject n the Workers Compensation provision Ofthe Luhor Cade,you must
T� fonhwithcamply with such provisions or this BUILDING FEE
G permit shall be deemM revoked.
0. (] CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz 1 hereby affirm that them is a construction lending agency for the perfasm once of - ELECTRIC FEE
O the work far which this permit is issued(Sec.3(197,Civ.C.)
tr Lenders Name
0 [(-,• Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
LSI I certify thin 1 have mad this applicmion end sum that the above information is MECHANICAL.FEE
Q. cancer. l agree to comply with all city and county ordinances end state laws relating to PERMIT ISSUANCE
y building construction,and hereby amharire representativesofthiscity to enterepon the CONSTRUCfIONTAX
U Z above-mentioned property rat inspection puryoses. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep homeless lite City of Cupertino again
liabilities,judgments,costs odenpences which may in any way mgeimt said City AIR HANDLING UNIT(TO IO,tNgI CFM)
in onseyuenc alba greening40(this pyrlrsy. - /)
AIR HANDLING UNIT(OVER IO,fI00 CFM)
ignature of Applicam/Contrecmr m EXHAUST HOOD(WIDUCD PAID
I(AZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building occupanumre ar herMle heordous material HEATING UNIT(OVER 100,000 BTU) TOTAL:
o defined by the Cupertino Municipal Coda Chapter 9.12.end the Health end Safety
Cede,Section 25532(a)7 VENTILATION PAN(SINGLE RMID)
❑Yes ❑No
ISSUANCE DATE
Will the aMlicanarfummbuildingocuWtuoequipmmiordevicawhichemit BOILER-COW LIHP OR 100,000 BTU) ,
allows air cormorants o defined by the Bay Area Air Quality Managemem BOILER-COMP(OVER IW."BTU) �' p
El ❑No NEW RESIDENTIAL MBCH. SQ.PT.
J 1 have reed the hamNom matenals requirements under Chapter 6.95 of the R ']O 194 9
Cahoon.Health&Safety Code,Sections 25505,25533 and 25534.1 understand that e'1 lj /I
if the building does not currently have a tenant,that it is my responsibility to notify the /s `f
occupant of the requirencons which must be met prior to tomo,of a Cetifmam of C1l�'u/- p
Occupancy. Lr llV r,
Owner or authorimdagent Date TOTAL: ISSUED DY: ' 1
OFFICE