26025 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO' PLUMBING-MECHANICAL - PERMIT NO. 26025
BUHAINO DIVISION APPLICATION/PERMIT
BUILDING PROJECT IDENTIFICATION
�.,BUILDING ADDRE1545k, n�� ^f—I1 { � ) �y�o �(.y11 r SANITARY NO. AIPPLICATION S`UUUBBBMfITALDATE
KOaOO�W C/IV 1�{J�ME: t{ONE:/• �I.IT SSCNOtTN CTOR'S NAME:c'I _ LI N L L
ARCHITECT/ENGINEER: LIC NO: I AD S' - /✓ ^t I'
CONTACT: PHONE: BUILDING PERM/TI O
QTYELECTRIC PERMIT FEE.
266-911
� '] B DO X PLUMB CH
a 0 p(.5`J-g7l PERMIT ISSUANCE i.
LICENSED CONTRACTOR'S DECLARATION - APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Amz Ihereby affirm thrill ma licensed underpmvisionsofChapter9(commemeingwith
POO Section 7000)of Division 3 ofthe Business and Professions Code,and my licerue is in 'PANELS
Fye Up full Porte and effem.
VVI License Class Lic.tt UP TO 200 AMPS
h 6 a Dae Contractor 201-1000 AMPS
2Orcoir Z, ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOW AREA S/SSo TFT.
O o,t O I understand my plans shall be used as public mcorde. ^/'� f.{,.
< BI SIGNS ELECTRICAL /Ulr U
Q Licensed Professional
E 0r , OWNER-BUILDER from
mECLARATION SPECIAL CIRCUIT/MIS&
W O y U I hereby affirm that I am exempt from the Contractor's Co a:cense Law for the
W 3 4 vHa following reason(Section construct,
Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
W wee.] which requires issuance,permit to cutes the,atm,,improve,demolish,fi repair any svucmre -
�}o thiormiacenedpalso rmarst me
provisiont nor s
Co men'sLicele signedLaw((Chaptementer
POWER DEVICES
4 O�O that he is licensed with
Sactiam Ne provisions of the Comment's Litems Lew(Chapter
0.00. 9(commencing with Section 70IX)of Division3of Ne Business and Professions Code) SWIMMING FOOL ELECTRIC VALUATION
W.-rn or that he is exempt therefiom and the basis for the alleged exemption.Any violation of
Sect70315 b
y for a
OUTLETS-SWITCHES-FIXTURES
Y ion . y anapplicant permit subjects the IF plicant m a civil penalty o —` (J
not more than five hundred dollars
� ❑ I,aeownerofthe property,ormycmployeeewi[hwegeses[heirsolecompensetion, I NEW RESIDENTIAL ELECTR —SQ.Fr. STORIE1 TYPF.CONSTRUCTION
a 3- will do the work,and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Contractor's License Law does not apply to en owner of
property who builds or improves thereon,and who does such work himselfor tlwugh his DEC.GROUP RES.UNITS
own employees,provided that such improvements arc not i mended or offered for sale.If,
however,the buildingor improvement is sold within one your ofcompletion,the owner- -
builder will have the burden of proving that he did not build m improve for purpose of
sale.).
❑ I.asownerofthepropeny.amexclusivelyconvactingwiNlicensedcmuacmrem QTY. PLUMBINO PERMITFEE FLOOD ZONE APN
construct the project(Sea.7044,Business and Professions Cade)The Convector's
License Law does not applythairvierofpmpeny whobaildsorimpruves 0assaw ,and PERMIT ISSUANCE
whocantracts forsuch projects withacontra encs)licensed pursuent to the Contractofx
License Law.
, ALTER DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ l am exempt under Sec. ,B&P C for Nis reason OUTSIDE FEE
BACK FLOW PROTECT,DEVICE SANITARY Y N
Owner Dam DRAINS-FLOORROOFAREA,COND. RECEIPT is
, ,
WORKMAN COMPENSATION DECLARATION . SCHOOL TAX YN
❑ Ihereby affirm mall haveeeertifcate of consent to self-insarc,oracenificete of FIXTURES-PER TRAPRECEIPT#
Workers'Compensedonlnsur ecoracenif,dcopythereof(Sec.IIM,LabCIwhich - PARK FEE Y - N
covers all employee'sundenhis permit GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT N
Policy# BUILDING DIVI I FEES
Y�
[3 Certified copy Is hereby[furnished. PLANGAS-EA.SYSTEM-OVER 4(EA) CHECK FEE
❑ C
'erCenified copy is filed with me city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE O ref'
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP DO ALI SMIE
COMPENSATION INSURANCE
(This section need not be,completed ifthe permit is for one hundred dollars($100) SEWER-SANITAR 2 1 RGY�•'EE
orless.)
I certify that in the performance ofthe work forwhich this permit is issued,l shall WATER HEATER
nut employ any person in any manner so as to become subject to the Workers' PAID
Compensation Lawsof California. Date WATER SYS EMIR Dete Receipt#
0 z Applicant -
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESID PLA#. -SQ.FT.--- TOTAL:
become subject to the Workers Compensation provisions of the Labor Cade,you must BUILDING FEE
forthwith with comply with such provisions or this Feteshall he deemed revoked. 01
LFI A CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agaacy for the performance of
Z TOTAL: ELECTRIC FEE
the work For which this permit is issued(Sec.3097,Civ.CJ
Lender's Name PLUMBING FEE �.
Lender's AddressQTY. MECHANICAL PERMIT FEE
U 1 certify that I have mad this application and state that me above information is MECHANICAL FEE
correct I agree to comply with all city and county ordinates and seem laws calming in PERMIT ISSUANCE /
I F^ builtlingcrnsauction,end herehy authorize mpmsenuuvee oflhiacity menteruponthe CONSTRUCTION TAX
[� y above-mentioned pmpeny for inspection purposes. ALTER OR ADD TO MECH.
F7
(We) gree to save,indemnify end keep harmless the City of Cupertino against
liabili.1e eats,chats and expenses which may inanyway acemea,dest id City AIR HANDLING UNIT(TO 10,000 CFM) -
in c go a^of the gran of this permit ���
n AIR HANDLING UNIT(OVER 10,000 CFM)
at Appren Comectur Data EXHAUST HOOD(W/DUC'D PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Receipt#
Will the applicant in firm,,building occupant store or handle hazadem,msterisl HEATING UNIT(OVER 100,0(10 BTU) 'TOTAL:
as defined by the Capenino Municipal Coda,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? a VENTILATION FAN(SINGLE RESID)
❑Yes No
BOILER-COME(3HP OR 100,000 BTU) I ANCE DATE
_ Will theupplicanmrfutumbuildingoccupent usaequipmentordeviceswhichemit '
h zardous air cnntamiaenv as defined by the Bey Area Air Quality Management BOILER.COW(OVER 100,000 BTU)
District? M"ppppRR — 9 1994
❑Yes No NEW RESIDENTIAL MECH. SQ.FT. a`
'1
1 have read the hazardous materials requirements under Chapter 6.95 of the 11�r'(�(- VUI'GFTI IIVV
Califomiu Him"& alry Code,Sections 25505,25533 and 25534.1 understand that _
if the buildin nen0y have etenent that it is my responsibility to roti the
ex ant ¢h must be met prior m issuance of a am to of
Occupy y'.
Ow authorize agent Dr L ISSUED111
OFI-lUt