26029 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO so. .D>RG-FL - PERMIT NO. 2^ O^9
APPLICATION/PERMIT PLUMBING-MF.CHANICAI, b L
BUILDING DIVISION BUILDING PROJECT'IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLIC,TIONrySUBMI'1TALDATE
/&C 1114a UNITN LOT# I ` q L
OWNERS I HONE: CO ACfO 'S NAME:ja 1
Ned I N/C CONTROL N
AKCl1ITBC'1'/FNGIN ER: LIC NO: ADD R S
g
ONTACM PHONE: " EPCRMIT FEE
11 BUILDING PERMIT INFO
QTY �'� t 81CT7iIC - -
" '•' ��' 4"" 4: BL E PLUMB MECH
PERMIT ISSUANCE El 13
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
GKZ Iherebyafff) IIUnsWunda ndenifesof Cha�9(commencise withFJCO ����
Clan Sectio herchy if Di nsuncluca Business erind rofesso[Cha andmyencing is in PANELS
y�F full force undeffect.
6Z Licenuem" Lic.N UPT02M AMPS
ti6a Doc�-. —Conuutor MI-M3(I AMPS
Z OFyZ�. • - a ARCHITECTS DLL ON OVER IOOOAMPS SQ.FT.FLOOR AREA , $/SQ.FT.
q I understand my plans shall o used m public records.
P-I='" SIGNS ELECTRICAL r A
Qga,¢ Licensed Profeuioml OWNER-BUILDER DECLARATION SMCIALCIRCUIT/MISC. 1�^ p p
ED IN
aN W U 1 hereby air,.that I um exempt from the Contmnora License law for the 1!✓ II II
0+tr-r~¢n following mason(Section 7031.5,Business and Professions Code:Anyciryormunry TEMP.METER ORPOLE MST. II V'
TER
4.J Gan J which ra,m es a pertain to consomt,alter,improve,demolish,or repair any awcture
Y� prim to its issuance,also mgviros the applicant for suchpemtitto file a signed oeumrnt POWER DEVICES
K Q p that he is licensed pmsuanuo the provisions of the Cmarecm's License Law(Chapter SWIMMVALUATIO
aS4) 9(commencing with Section 7000)of Division 3 ofthe Business and Professions Code) MGPOOLELECTRIC
t`I or that he is exempt therefrom and the basis for the alleged exemption.My violation of OUTLETS-SWITCHES-FUTURES
6 Section 7031.5 by any applicant for a permit subjects the applicant m a civil pertafty of
not more than five hundred dollars($5100). NEWRESIDENTIALELECR .PT.
❑ Lou ..
wogesutheimolecampenution. S Q STORIES TYPE CONSTRUCTION
a3-- will do the work,and the structure isnotintandedoroffered ha-mic(See.7044,Bminess
and Professions Cade:The Contractor's License law does not apply to an owner of
property whotholds orimproves lhemon,and whodoes such workhimselforthrough his
ownOCC.GROUP RES.UNITS
employees,prov orithatsuchent is sold
wit ere not intendedmoffered formic.If.
however,thebve due andenovementissa,be within build 0,will hove the burJrn,(proving that he did trot build or improve for putpou of
sale.). QTY. Sr��.' PLUMBING PERMIT FEE
❑ Les ownerof the property,nm exclusively cdmracting with licensed convecmrsno FI.GDD ZONE APN
rostrad the project(Sea 7044,Business and PrIfeuiom C—;,The Conuactole
Lioenu Lawdocsnotapplytu we oconerofp llwhobuildamimprovmthateon,and A PERMIT ISSUANCE
whocontmcts forsuch projats with a contracmried licensed punuanno Ne Conwcmrs
License Law. ALTER-DRAM&VENT-WATER(EA) FEE SUMMARY
❑ 1 on exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE ID
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF.ARI:A.GOND. RECEIPT#
WORKMAN COMPENSATIONDECIARATION SCHOGLTAX YN
❑ Thereby affirm thetlheve acertificata ofcomem to aelGinsum.orecenifieom of FlXTIIRES-PE0.TRAP RECEIP #
Workera'Compensation Insurance ora cenified copy theuaf(Sce.38W,Lab C.)which PARKME Y N
coven allit. GAS-EA.SYSTEM4 INCAOUTLETS RECEIPTN
em to a
Polity N BUILDING DIVISION FEES
CompanyP Is GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ CerfifleMpyT&Tcriby fumishcd.
�Certified copy is filed with Ne cc nspection division. GREASEIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXENIPDON FROM WORKERS' GREASF.TRAP SOILS FEE
COMPENSATION INSURANCE
(This sectionmealmn bccomplctcd ifthe permit is fmone hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
In leas.)
I certify that in the perfomunecof the work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ any person in my manner m m In become subject to the Worked PAID
Compensation Laweof Celifomia. Doe WATER SYSTEM/TREATING Doc Receipt#
zz Applicant
O NOTICE TO APPLICANT:If,after making this Ceriftcau of Exemption,you should NEW RESIDENTIAL PLMB. SQ.VT. TOTAL:
(q become subject to the Workees Compensation provisions of the Labor Code,you must BUILDING FEE
forthwith comply with such provision,or this pemdt shell be deaW nrevoked.
W SEISMIC FEE
6i (] CONSTRUCTION LENDING AGENCY
1 hemby affm N
uet there ie a conswction lending agency for the performance of
U O TOTAL: ELECTRIC FEE
the work fur which this permit is issued(Sec.3097,Civ.CJ
Lender,Name
O Lenderh Address QTY:''y5, MECHANICAL PERMIT FEE PLUMBING FEC
1 certify then I have read this application and smite that the above information is ' "' MECHANICAL HE
�" W correct. legree mcomply with all city andcounny ardinanea end sumlaws rtleting to w PERMITISSUANCE
E" building construction,and hemby aunhomea mpmsenutivesofthis city noemer upon the CONSTRUCTION TAX
U 7 move-memimm Property for inspection putus
po . ALTER OR ADD TO MECH.
(Wc)egme no ave,indemnify and keep harmless the City of Cupertino eg t
liabilities,judgments,costs andexpenses which may many wayaccrue aian at ry AIR HANDLING UNIT TO 10,000 CFM)
in consequence of the grunting ;mit
' AIR HANDLING UNIT(OVER 10,000 CFM)
ile
scan odmm ".fEEXHAUST FOOD(W/DUCD
PAID
IIAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO Ift"BTU) Dom Receipt III
Will the applicant or future building occupant state or handle notorious materiel
as defined by the Cupmmo Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100."BTU)
Code.Section 25532(a)7 VIMTILA'DON PAN(SINGLE RMID)
❑Yes ❑No
ISSUANCE DATE
Will heapplicant orfulumbuildingcecupant useequipmrnnorde,ices which emit BOILER-COMPOUPOR 100,000BTU)
hananlons air connminand as defined by the Bay Arm Air Quality Management BOILER-COMP(OVER 100,1X0 BTU)
District? ❑Yes 11 No NEW RESIDENTIAL MECH. pp SQ.FT. P " ' D
I have;cad the hmadous matemme requirements under Chapter 6.95 of the JAM 19
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand Nat 199-
if the building dons not cuvmdrnan
y have a tt,that it is my responsibility to notify the J
occupant of the requirements which must be met prim to issuance of a Certificate of Cr
Occupancy. VV
Owner or authndud agent Date TOTAL: ISSUED BY: