26163 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO APPLICATION/PERMIT PLUMBING MECHANICAL
PERMIT No. //�/k1� 1 ff� I(�
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION `V 1 V V
BUILDING ADDRESS: /j SANITARYNO. , APPLICA OO���NS(((UBMITTALDATE
// UNIT# LOT If
_/[( '
OWNERS NAME: OPH0 E: CONTRACTOR'S NAME: LIC NO: f I_
OO'Vp ) NIC CONTRO.#
CHITF. (NEER: IC NO: ,ADDR SgSj-���rD LnJ `_/ 2O _ ❑
nrvTACT: PxoNE: QTY. ELECTRIC PERMIT U JFEE BUILDING PERMIT INFO
BLDG ELECT PL MB MUCH
PERMIT ISSUANCE ❑ El ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
MWz Iherebyaffum thatlam licensed underprovisionsof Chapler9(ctmmencingwith
P400 Section 7000)of Division 3 of the Buyness and Professions Code,and my license is in PANELS
y�j fall II foand effect,A c[- b 33
I;,GGZw License Class
N �Lic.q� UP TO 200AMP5
=�, Dtlre Contrecmr 201-1000 AMPS ccF��1... �p
ZO`r'4 ARCHITECTS DECLARATION OVER 1000 AMPS — FT gOWt. $/SQ'FT.
0,�rd p I understand my plans shall be used as public records. - llhl'..s»---... fl IPPV,
HPLicensed Professional SIGNS ELECTRICAL _OWNER-BUILDER DECLARATION SPECW.CIRCUIT/MISC. I � it I hereby affirm Nat I am exempt from the Contractors Licenae Law for the �' �J W C w following reason.(Section T031.5,Business and Professions Code:Any city memory TEMP.METER OR POLE FIST. /'�/vr
E1 co which requires a permit to commute,alter,improve,demolish,or repatr any sticture ( /
i-� priorto its Issuance,also requires the applicant for such pemdt to file a signed statement POWER DEVICES
that he is licensed pursuant in the provisions of the Contractor's License Lew(Chapter -
ca 9(emmnencing with Section9000)of Division 31fthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
_w or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
i Section 9031.5 by any applicant fora pewsu
it bjectathe applicant toe civil penalty of
O not more than five hundred dollars($500). NEW RESIDENTIAL ELECTR, S .FT.
tal m ❑ I,asawneroftheproperty,ormyemployeeswithwaguastheirsolecompemafion, Q STORIES TYPECONSTRUCTION
y ME dothe sork,and theshucmre isnotintendedoroffered formic(See.9044,13usmess
and Professions Code:The Contractor's License Law does not apply an an owner of
propenywhobuildsorimprovesthereon,andwhodoessuchwoik himselforthroughhis
owromployees,provided that such improvernmaarenot imendedorofferefficaule.If, OCC.GROUP RES.UNITS
however,the building orimprovement is sold within one yearofin mplefion,the owner-'
. . builder will have the burden of that he did not build or int TOTAL:
proving prove for purpose of
n1eJ.
❑ I,aloe potill(Sec. rty,am exclestveryctaoaa,ionsiCods)The Commences
QTY' PLUMBING PERMIT PEE FLOOD ZONE APry
eicanse the project(Sec.oano Buainesa and Professions Cods)The Convectors
Licensemses Law fosnotapplymawitharafpropeny who
sed puodmpn the thereon,and PERMIT ISSUANCE
IcecoeL wo forsuchprojec[swi@econoacmr(s)IicensrA porauanvo the Convector's ALTER-DRAIN&VENT-WATER(EJO FEE SUMMARY
❑nl i n exempt under Soc. ,B&PC for this reason BACK FLOW PROTECT.DEVICE + OUTSIDE FEES
SANITARY Y N
Owner Dane DRAINS-FLOORROOFAREA. RECEIPT#
WORKMAN COMPENSATION DECLARATION , , SCHOOLTAX N-
OLI
herebyieffnn that l have a certificate ofeousentto self-hsure,or a cenifcnte ofPfXTURES PER TRAP _ RECEIPTIf
Workers'Compensation Insurance or a ambled copy thereof(Sec.3800,Lab C.)which PARKFEE - Y N
covers all emptoyeee ands pe n GAS-EA.SYSTEM.I INC.4 OUTLETS RECEIPT#
Prue « �i�1A 2'
Y BUILDING DIVISION PEES
Company� � )
❑ Certified copy is hereby famished. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
Certified copy is filed with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR
GRADING FEE
' CERTIFICATE Of EXEMMON FROM WORKERS' - GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(Thissecdonncednonbe completed ifthe permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.2001"T. ENERGY FEE
orless.)
Iconify that in the performance ofthe work forwhich this permit is issued,l shall WATER HEATER W/VENT/ELECTR _
not employ any person in any manner so as,to become subject to the Workm' PAID
Ci mpenaation Laws of Celifomla. Data WATER SYSTEM/TREATING Date Receipt«
Q z Applicant ,
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
become subject in the Worker's Compensation provisions of the Labor Code,you must
> forthwith comply with such provisions or this panni[shall be deemed revoked. BUILDING FEE ,
CONSTRUCTION LENDING AGENCY 'SEISMIC FEE
z I hereby affirm that there is a construction lending agency for the performance of TOTAL: ELECTRIC FEE
0 the work for which this permit is issued(Sm.3097,Civ.CJ
Lender's Name I PLUMBING FEE
0 U Lender's Address QTY. MECHANICAL PERMIT PEE
L) I certify that I have reed this epphase n and state that the above information is
OW. carbon,Iagree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL PEE
buildingeonsun
ctic ,and hereby suthou andrepresentatives ofthis city enter upon the
V z CONSTRUCTION TAX
above-mentioned properly for inspection purposes. ALTER OR ADD TO MUCH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilwits,udgmems,costs and expenses which may in any way amore against said City AIR HANDLING UNIT(TO 10,000 CFM)
in consequence of the granting of this Permit.
AIR HANDLING UNIT(OVER 10.000 CFM)
Signature of AppllcaruContramor Dow EXHAUST HOOD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE IHEATING UNIT(TO 100,001)BTU) Date Receipt#
Will the applicant or future building accupam store or handle harardaus material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defned by the Caperton Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25512(a)?
ID Yes ro VENTILATION FAN(SINGLE RESID)
i►N
Will theepplicantorfmurcbuildingoecupant useequipmentordevices which emit
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
'..Won,an,contaminants as defined by she Bay Area Air Queliy Management BOILER-COME(OVER 100,000 BTU) p
istrict? K
❑You .2r. - NEW RESIDENTIAL MECH, SQ.FT.
1 have read the harardaax materials requirements under Chapter 6.95 of the MAY 2 5 1994
California Health&Safety Cade,Sections 25505,25533 and 25534. I understand that '
if the building does not currently have a tenant,that it is my responsibility m notify the +�
�ups the re air ants which must be met prior to issarme uf✓Ccrtif¢a a of _ CIl Vr V U I IN I
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE