26107 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO rC PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL - C O
BUILDING DIVISION BUILDING PROJECI'IDENTIPICA9'ION v
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITALDATF.
UNIT# IAT#
OWNE SNAM.: •PHONE: CO CfOR'S MB' LIC NO:
7 N/C CONTROL# '
RCH G LIC NO: ADD RESUP 6AA�vj -.....9s ❑
CONTACT: PHONE: :., xp i-�* +. �f BUILDING PERMIT INFO
615 `wr E8ECTRIGPERMIT PEE Jfj�Cjy
/W//�
f DG ELECT PLUME -1-71
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Zoaz (hereby af]ME hatl amlicensedunderprovisionsofChapmr9(commere ,n IN
400 tion 000)of Divisim 3ofthe Business and Professions Cade,and my license is in PANELS !-1`a'A
yy� 'K
foreeeadeffect \ ` l
<zw License Lica UPT0200AMPS _
y Q s
Data--�Cantracmr 201-1000 AMPS �
ZOrceita ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
I understand my plans shell he used res public records. O
�
SIGNS ELECTRICAL
Licensed Professional l
yy Q OWNER-BUILDER DECLARATION jPECIALCRiCUIT/MISC.
Com$
0,F 1 hereby affirm that 1 am exempt from the Contractor's License law for the
3 a w following reason.(Section 703 L5,Business and ProfessionsCode:Any city memory TEMP.METER OR POLE INST.
tiEZ01 which moraines aperminoconstmct,aheqimprove,demolish,orrepairanysbunum
Y� poor to its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
oc QOO that he is licensed pursuant to the provisions of the Canlranars License law(Chapter
an. 9(commencing with Section]000)of Division 3 Edge,Buvinessand Professions Code) SWTMMMG POOL ELECTRIC VALUATIOf�_
n e^y or that he is exempt therefrom and the basis for the alleged exemption.Any violation of ^ • _ `CY
�ZQ Section 7031.5 by any applicant for aprnnit subjects the apPlicent meeivil petWty of UTLEI'S-SWITCHES-FLXT'URES �� Lj aNN/
C0 nm more thun five hundred dollars(5500). NEW RESIDENTIAL ELECIR _SQ.FT. / TO FS TY 'TRU ION
Gm ❑ I.asownerofthepmpmy,ormycmployeeswithwagesasthc"olecompcnsadon, — B TV 11 G� �_
ys- will do the Evans. ndthcMeturehomiamndedarafferedfar We SEE.7044,Business oYVll 1l' .,a
and professions Code:The Convector's License Lew does not apply to an owner of
propcny who buildoorimprovathcaon,anJ whodeee suchworkNmulforthroughhie0 1111
own employees,provided that suchimprovements are not inuareadorofibred(orange.if, N17
however,thebuilding or improvement is sold within one yearnfcampletion,the owner.
builder will have the burden of proving that he did not build or improve far purpose of
sale*)
❑ ' QTY;,= PLUMBING PERMIT
Las romW
flhe lrmmy,aeaclusively contracting with licensconun
actotn �,
onawet nroject(Sec.7(N4,Business and Professions Cade:)The CEatncmra ,r,-j,
License Law does not apply to an ownerofpropeny whobuildsor improves thereon,end PERMIT ISSUANCE
whocomusetsfor such projects whhaconlreclor(s)licensed pursuannothe Connectors ALTER-DRAIN@VENT-WATER(EA)
License law. FEE SUMMARY
❑ 1 am exempt under Sec. ,B @ P C for this reason BACK FLOW PROTECT.DEVICE OuTS -
SANITARY YN
Owner Date DRAINS-f100RROOPAREA,COND. RECEIPT#
, ,
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ihemby affirm therlhnveecenificem of canxmlo self-imurc,or.veniflemeo( URES-PER TRAP RECEIPI'M
Worket%Compensalion Insurance or a certified copy lhnrcof(Sec.380QLob C.)which PARK FEE Y_N
Policy all employee's under permit. SIO/�7l GAS-EA.SYSTEM
INC.40IITLEfS BUILDING DIVISION FEES
Policy# Gl% (D .i ^
Y GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE Q
nified cop,is hereby furnished.
Cenified ropy is filed with the city Inspection division. - GRPASFJINDUSTRL WASTE INTERCEPTOR GRADING TEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASE.TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed if Ne permit is forone hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the performance of the work for which this permit is issued,l shall WATER HEATER W/VENTIELECTR
nor employ any pe.an in any maturer sic ns m bacome subject to the Work. PAID
Compensation Lawsod Califomis. Dom WATERSYSTE LTREATING Date Receipt#
z Applicant
ZQ O NOTICETO APPLICANT:Ifafmr maeir,mis Cerofemeof Exemption cor should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
become mbjwno the Workers Compensem.,mvinmmoflhe labor Codman must
foMwith comply with such provisions or this permit Nell be deemed revoked. BUILDING FEE
W Q
CONSTRUCTION LENDING AGENCY SEISMICFEE
z I hereby affrd that there is a crnatrvelion lending agency for the performance of TA ELECTRIC FEE
U O the work for which this permit is issued(Sec.3097,Civ.C.)
tr Lender's Name "•'' PLUMBINGFEE
Q CrJ Lenders Aad ars QTY,• ''- "
,: MECHANICAL PERMIT _FF-li
I certify that I have read this epplicmion end state th d&a above Infomant. is + `°f" t "
>'1 Uja. correct.In agree to comply with all cit and count confinement vW nam laws relating
m PERMIT MECHAMCAL FEF.
&' pYwm Y YE g
building construction,and hereby anhoore xpresentxtivesof thisciry to enter upon the CONSTRUCTION TAX
U 'z above-mentioned proper for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep hamdem the City of Cupertino Umnvt
liabiligies,judgments,costs andexpenxswhich may in any way ettmeegdnst said City AIR HANDLING UNIT(1010,000 CFM)
in consequence Ef a gm ting of thio pumit.
3 AIR HANDLING UNIT(OVER W."CFM)
ignmurc of, IicanUConvecmr 1.9s - Ll
Da EXHAUST HOOD(W/DUCq PAID
HAZARDOUS MAWWTERIALS DISCLOSURE HEATING UNIT(TO 1011,0(10 BTU) Data Receipt It
Will flia.,licant or future building oecupam store or handle husardous material HEATING UNIT(OVER 100,000 BTU) TOT
as defined by[be Cupertino Municipal Code,Chapter 9.12,and the Health arta Safely
Code,Section 25532(,)1 13 Yes ❑No VENTILATION FAN(SINGLE BESIDE
ISSUANCE DATE
Will theappliermErfuturebuildiagoccupsnt tax eq uipmemordevicas whichemit BOILER-COMPOHPOR 100,000BTU) PAID hazardous air contaminants as defined by the Bay Area Air Quality ManYllearm BOILER.COMP(OVER 100.000BTU) 0 D
Oistriml
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT. gpgI�Tfl� 1QQ�ny
I have read the hazaudous materials requirements under Chapter 6.95 of the OR � 8 1` 9 o
Colifnmia Health @ Safery Coda Sections 25505,25533 end 25534. I understand thm y+
if the building dwas not currently have a tenant.dorb is my responsibility to notify the Cl l Y tar wilth
oecupam of the tequirements which must ed met prior m issuance of a Cenificam of
Occupancy.
Owner or authorized agIts 2n,09f
ent Dum TA ISSUED BY:
OFFICE
^-5