26783 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO - .-EECrRTCA. PERMIT NO.
BUILDING 6IVISION APPLICATION/PERMIT PLUMBING-MECHANICAL A L` O O
BUILDING PROJECT IDENTIFICATION L v O J
BUILDIN ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE.
Ulm. 1 4 LOTH
OWNE144M: PHO RA TOES NA LIC NO:
�at `'t eyf 1 %J N/C CONTROLp
1RCHI 'C GINEER: LICN RESS: El
O•� —I
CONTACT: PHONE:
QTfY ,',� Y I EL04TR. IC`PE IT. FE8 BUILDING PERMIT INFO
Bg ELECT PLUMB MECH
PERMIT ISSUANCE �.I1
mthatI EDCONTRnderpo CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL _ J�nu.nacr CRIefl10 I�
pyZ Ihercby uffirLIC LAam SEDlicensed CONTRACTOR'S DECLAR TIO (commencing with `I
ts10O Sedion]000)of Division Jnfthc Business end Rvfeuions Code,and my liana is in PANELS
h W full force nnA effe t.
aZ icenxe Clnss��Liap IIP TO 200 AMPS
vii_ m Canunctor 201-1000 AMPS
ZO Z. — " A .lTCMICDECIARATION OVERT AMASS SQ.FT.FLOOR AREA $/SQ.FT.
Z. G 1 undersand my plans shall he used u public records.
Fn W SIGNS ELECTRICAL
Licensed Professional
r,XO0.0 I hereby afPom that I ams BUILDER
Bram NeL DECLARATION SPECIAL
License Lew for the SPECIAL CIRCIRT/MISC.
W k O y following....(Section]03 1.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
y which requires a permit m.1.1,alter,improve,demolish,m rcpir any structure
poor to its issuance,du realities the applicant for such permit to file a signed seamen POWER DEVICES
ty p that he is licrnseAuu
puanno the provision of the Comracur'a License Law(Chapter
dKe 9(commencing with Section]0110)of Division 3 ofthe Businessand Profession Code) SWIMMING POOL ELECTRIC VALUATION
1y_,, or that he is exempt therefrom and the basis far the alleged exemption.Any violation of OUTLLTTS-SWITCHES-FIXTURES
Section 7031.5 by any applicant for a permit subjects the applicannn a civil pendry of
not more Nun five hundred dollars($500). NEW RESIDENTIAL ELECTR _SQ.FT.
W ❑ I,nownerofthepmperty,Ormyemployaswithwagesutheinolewmpensatian, STORIES TYPE CONSTRUCTION
will do die work,and Neswmumis not itnendedoroffcred forule(Sec.7044,Business
and Professions Code:The Contractors License law does not apply to so owner Of
proper whobuildsorimproves therma,and whodaa such workhimulfmthmughhis
ownOCC.GROUP RES.UNITS
ever,oyees,providuimproveh impmvemcmhin cam yearof dOroffe at,due ow.If,
however,the building or improvement is hath within one year of completion,Ne owner-
bals.). will have the burden of proving that he did not build or improve fm purposeof TOTAL:
ale.). Qry1,++". PLUMBINGPERMIT FEB
❑ Laso a pioneer(Smpenyamexdues and anri.wird de:) hi,Co mere.to MOOD ZONE. APN
construct the project(gee.]044,Business end Professions Cade:)The Convectors PERMIT ISSUANCE
License law dors not apply ct on ower M proper who licensed
m ire provu Corecn,and
Lkero,ass fnrhuch projects with aconvmtortJlianed pumuantto tla Contrecbrs ALTER-DRAINA,VENT-WATER(EA) FEE SUMMARY
Li l arnw. -
❑ I em exempt under Sec. ,B&P C far thio reason OUTSIDE FEES
BACK FLOW PROTECT.DEVICE
SANITARY YN
Owner DemROOF,AREA, RECEIPT#
WORKMAN COMPENSATES DECLARATION DRAINS-FLOOR. COND. SCHOOL TAX YN
❑ Ihemby affvmNetlheveacerdficem afconsem to self-insure,oruartifcme of RF.CF.IPI'M
I Waken'CompertutionlmurenceoreanifcJ copy thereof(Stt.3g00,LabCJFIXTURES-PER TRAPwhich PARK FEE VN
covers,all employee'a under this Permit. GAS-EA.SYSTEM-]INC.4 OUTLETS RECEIPT#_
policy N BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Carifiedwpyisharebyfumishad.
❑ CsniliW wry is filed wird Ne city impemion division GREASIVINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need nothe completed ifthe permit is forma hundred dollars(SIW) SEWER-SANITARY-STORM EA,2fKIFT. ENERGY FEE
or leve.)
I certify that in the performance ofthe woo for which this pemtit is issued,I shall WATER HEATER W/VFNT/ELECTR
Out employ any person in any manner an u to became subject to Ne Worker' PAID
s Compensation Luwsof Celifamis. Dam WATER SYSTEM/TREATING Dam Receipt#
o,z Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemplar,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
N become subject o the Workers Compensation provisions ofthe Labor Cade,you ant
forthwith comply with such Provision in this Permit shot be deem>d revoked. BUILDING FEE
aM CONSTRUCTION LENDING AGENCY SEISMIC FEE
z ,I hareby Of Net Vert is a construction lending agency for the performance of TOTAL: ELECTRIC FEE
L) O the wad for which this permit is ismed(Stu.3097.civ.C.)
Indere Name
LC+ LeQ '^ PLUMBING FEE
O Lenders Address 700..; "MECHANICAL PERMIT P88
w I anify that I have read this applicdion and Bute that the above infosmmion is MECHANICAL FEE
wrreeL I agree mcomply with all city and countyardirearma and state laws relating to PERMIT ISSUANCE
V
buildingconsvucimn,and hereby authorise repreuna ises of thiscity menmrupn the I CONSTRUCTION TAX
(, � above-menuonN properly fa inspection Pntpaus. ALTER OR ADD TO MECH.
(We)agree m ave,indemnify leu the City of Cupertino against
limilitin,judgmenu,cosa nndex awhichmaym yway amme against said City AIR HANDLING UNIT(TO 10,1100 CFT4)
in comosumoo a ie permit.
AIR HANDLING UNIT(OVER IB,IKKI CFM)
S a RIO,o pIicen omructor Data I EXHAUSTIIOOD(W/)UM PAID
IIAZARtureb MATERIALS DISCLOSURE
HEATING UNIT(TO 100,()00 BTU) Date Receipt#
Will the the Cupertino
or future building occupant start m andhandlethe
hazardoas d Salil TOTAL:
u defined by the CupeninO Municipal Cade,Chapter 9.12,and the I leilth and Safety HEATING UNIT(OVER 100,0011 BTU)
Core,Section 25532(a)P VENTILATION FAN(SINGLE RPSID)
❑Yes ❑No
ISSUANCE DATE
Will the applicantorfuturebuildingwcupant useegvipmenmrdeviceswhich emit BOILER-COMP QHP OR 100,0011 BTU)
hazardous air contaminants as defined by Ne Bey Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
Distrin9
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.FT.
1 have mad the hassndous materiels requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand that
if the building does not currently have a reran,that it is my responsibility to notify the - �J
mmpnt of the requirements which must Ire met poor to issuance of o Cenificme of
Occupancy. \�}��► J^�
Osocrmmahnudagent Dam TOTAL: ISSUED BY: ��/w� ` • - -
OFFJ