26745APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO•.111.1
APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
PERMIT No.
26745
BUILDING ADDRESS:
SANITARY NO.
APPLICATI,,,OyyyN SUBMITTALDATE
UNIT# LOT#
111 aaa+++
' S AME: PHONE:
CONTMCfOR'S NAME: LIC NO:
V
N/C
CONTROL #
Ii RCIIITECT/E INEGR: LIC NO:
ADDRel ESS:
Cw _
1 INTACT: PHONE:
`f
W, E-LECTRIC PERMIT FEE
AUILDING PERMIT INFO
ELECT PLUMB MECH
$ 6 -A6 N f
';
PERMITISSUANCE
C
❑ ❑ ❑
LICENSEDCONTRACf 'SDECIARATION
1 hereby afTrte that I em Iiamued underprovisions of Chepmr 9 (commencing wift
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
PANELS
Section 7000) of Division 3 ofthe Business and Professions Cade. and my license is in
full Lome and effect.
License Clan Lic.It
UPTO200AMP5
Dam Contractor
201 - IOW AMPS
ARCHITECTS DECLARATION
I understand my plans shell b, used an public awards.
SQ. PT. FLOOR AREA
OVER 1000 AMPS
SIGNS ELECTRICAL
I
Licensed Pwfaseional
OWNER-BUILDERDECLAMTION'
SPECIAL CIRCUR/MISC.
1 hereby elfrm that 1 am exemptexcmM from the Conimcwta Law for the
TEMP. METER OR POLE INST.
following reason. (Section 7031.5, Business and e: my
Code: Any wiry or county
destorts
whichrequiresapermit acovuucm,alter imfinst demolish,mresitanyewesurt
improve,
prime its tensed permit m fix a signed comment
requires the applicant fthe
POWER DEVICES
palso
Co
thathe mis IicingMpursusmwthe provisionsof the Ce Basin is License Law (Chapter
9(commeis ixem with ec Division 3 ofthe Code)
PrAny
SWIMMING POOL ELECTRIC
VALIf�TJRN
from and)the edaincss nepdo
therefrom violation
onhm he 131.5 by tbemfmmandrr a baspermfortheasegedexlicant n. Anylperaionof
Section ]031.5 by any applicant for a permit subjects the applicant w e civil penalty of
11�/ssaa� i%r r
OUTLETS - SWITCHES - FIXTURES
not more than five hundred dollar (SSW).
❑ I,asownerofthepmNm,ormyemployeeswithwagesas B¢irwlecampensauon,
NEW RPSIDENTIALELECTR—SQ. FT.
STORIES
TYPECONSTRUCfION
11
will dothe work, and thesmacere isnot inlendcdmoRered formle(Sec. 713,114, Business
and Professions Cale: The Canruaer's License Law does not apply an an owner of
1 11
propcnywhobuihLsmimproves themon..nd whodnessuch work himselforthrough Ns
ownemployms,pmvidedthatsuchimprovementswenotimmndr oroffemdfmsile. If,
OCC. GROUP
RES. UNITS
TOTAL
however, the buildingor improvement is sold within one year of completion, Immsmr-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
I,mownerefmheprosny,amexclusivelyconmactingwithlicem conaactone
coHe pwjem (Sec. 7044, Business and Professions Code:) The Contracwr'.
Liana Lawdoesnmapplyroannwnerofpmsnywhobuil&orimpmvestheaan,aM
QTY.R _ -PLUMBING PERMIT F
FLOOD ZONLr
APN
PERMIT ISSUANCE.
CP
whnconuectsfn... ch projects wiNacomrictm(q licensed poste ilm Contmewea
License law.
ALTER-DRAIN&VENT-WATER EA
( )
FEE SUMMARY
❑ 1 am exempt under Sec. , B & P C for this as.
BACK MOW PROTECT. DEVICE
1
TARY Y N
RECEIFr#
Owner Dete
DRAINS- FLOOR. ROOF, AREA. COND.
a.� WORKMAN COMPENSATION DECLARATION
KIhembyaff,. that l have. eenificamofconurn w self-mummaexiffcatecif
Worked Compenamlon lmumnce meanified copy thereof(Sec. 3800. Lab C.) which
c.vv,a all empinyoax under thin pertnitA�r r� Q �
Policy p T V
SCHOOL TAX YN
FIXTURES PER TMP
PARK FEE Y I N
PARK
GAg- EA.gYSTEM-I INCA OIITIPTg
pU1LDINGRE-CE IO# �r S
r
. Company I M �-`aI +�1T—I�f
�Cmdf.xd co is hereby famished.
GAS -I?A. SYSTEM-OVER4(1?A)
PLANCHECK FEE Q
GREASFF%INDUSTRI. WASTE INTERCEPTOR
GRADING PEE
❑ Certified copy is filed with the city inspation division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 20OFT.
ENERGY FEE
(This section need nm becompleted ifthe permit isfm one hundred dollars EH0b
or less.)
WATER HEATER WNENTIELECIR
I certify the in Ne performance of the work far which this permit is issued, I shell
not employ any person in any, mwuter so as to become subject a the Workers
PAID
Compenmtion 6awsof California. Data
WATER SYSTENVIREATING
Da eceipt#
Applicant
NOTICETO APPLICANT: If, after making this Cerditcam of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
become subject to the Worker's Compensation provisions of the Labor Code. you must
forthwith comply with such provisions or this permit shill be deemed revoked.
BUILDIN �R
MISMIC 1. Wl
CONSTRUCTION LENDING AGENCY
1 hereby affirm Nat them is a construction lending agency for the cwtorance of
the work for which this permit is issued (Sec. 3097, Civ. CJ
TOTAL:
ELECTRIC FEF.
Lender's Name
QT,. ` MECHANICAL PERMIT FEF,
PLUMBING FIDE
Lenders Addmsa
1 certify that I have mad this application and sate that rhe above information is
correct. 1 agree to comply with all city and county ordinences and sate laws meeting to
"4" 'r'
PERMIT ISSUANCE
CHANICAL. FEE
building conswcrion,and hereby auth.e odar reseaauvnofltischy w emaupon the
above mentioned property for inspection purposes.
ALTER OR ADD TO MF•CH.
NSTRUCTION X
se
(We) agme m save, indemnify and keep hwmlece the City of Cupertino against
andexnsea which may in any way awerucagainsasaid City
coaape
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER 10.000 CFM)
in consequence of the growing of this permit.
EXHAUST HOOD(WNUCI)
[PAID
Signature of ApplicamlContmaor Date
HEATING UNIT (TO IW,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dem Receipt If
HEATING UNIT (OVER 100,00,01 BTU)
TOT -
Will the applicant or future building occupant srorc or handle hmnrdeus material
as defined by the Cupertino Municipal Code. Chaplet 9.12, and the Health arta Safety
VENTILATION FAN (SINGLE RESID)
a
Code, Sectin)5532LID
k_ ❑ No
ISSU CEDA
Will theapplicanmrfutumbuildinguausntuwquipmentmdevitta which emit
BOILER-COMP(3HPOR IW,00011M)
� 1�
BOILER - COMP (OVER 100,000 BTU)
h. ardia s air conmminana as defined by the Bay Ars Air Quality Management
L�
A Il iV
District?
' Yes 0 N
a
NEW RESIDENTIAL MECH. SQ. FT,
I have mad the hteardous materials requbemema under Chapter 6.95 of the
AUG 1 6 1994
California health & Safety Code, Sections 25505, 25533 and 25534. 1 understand not
if the building does not currently have a tenant, that it is my responsibility to notify the
ecu Ne ne,amments which r w issuantt of a Cer iftcam of
�1 L
Oil ( Qr
ll '
arc
7
\�� (Jk�Vren
ISSUED BY V Vav Vl _—
D
Ownerorauth red agent
TOTAL:
OFFICE