26127 APPLICANT TO FILL IN INFORMATION VIES HIN Heu Lanes-we DALL rvi e 1 rca.vests-I PERMIT NV.
CITY OF CUPERTINO PLUMBING-MECHANICAL /6 1 / 7
BUILDING DIVISION APPLICATION/PERMIT z7N:BU LDINO PR DRNr c T on:z:. L V 1 L
,i-t,4
SANITARY NO, APPI.IGTON SUOMTfTAL DATE
BUILDING ADDRPSS:
I..l fV UNITN LOTN
OWNERS N MF.: PHONE: CONE CTOR'S NAME' LIC NO: NiC CONTROL
QAJ
RCHITF /FNGIN[ER: LIC NO: A DRE( ❑ '
BS 6A
�.• CONTACT: PHONE: —r we µ vnI�a,
�9a v ' � iELDECNT0 PERMIT INFO
PLUMB M..E
C)� BLDG
PERMIT ISSUANCE ❑ ❑ WCN ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
pfZ Ihercbyaffren she,l am Heemubmder provlelomaclepler9(commencingwith
00CF, Section7MfYuf Division 3 ofshe Budmes aM PsofeasolormC ylicense is in PANELS
s6..�ZS LitenlforcCles afecle�3G Lic.X �'3 qp/ UPT01W AMPS
y Q so Dele 3=L41=.�'k` Conlrecmr a'"•'7 t01-IOW AMPS SQ.ff.ll(1(1R ARE SrCV.ll'.
xFy�, TRCHI=k SDECLARATION OVER IOW AMPS
OZ n^ I umlanund my plans shall be used v public recoNa.
OContractor
SIGNS ELECTRICAL
Licensed Nofeseionel SPECIAL CIRCUIT/MISC.
OWNER-BUILDER DECLARATION
60 is. 1 ngherebyrem affirm,hal 1 em erempt Tran the Conoecs Co e:MY Law for the
y�3 WFa following rcohan.(Section 7031.5,Business and ROMslmu Code:My city or county TAMP.METER OR POLE INS?.
uircn a Perim,to construct. w
Improve,dmrollrh.or repair any acturc
Ve which oeyPOWER DEVJCES
NX prim to its issuance,also requires the applicant for such permit o file uignMatetemant
<O that he is licensed pursuant to the provisions of the Cmoectora Licenv law(CLapte, SWIMMING POOL FaPCiA1C VALUATION
mm 9lcmmmeming with Se<tim?IXpl of Div0ian lof Ore Bualnw eM Prafessione Code)
or that W is exempt herefrom and tM bull fro she alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
Yon'
Section 7071.3 by my applicant for.permit.uhjacv the applicant toe civil penalty or
ret name tbv five hundred Jnllerr lSSWI. _
NEW RESIDENTIALELECIA _ SQ.FT. TORIES 'TYPti CY1N5INUCI'ION
witI Joth
❑ .11hawncraf@epropesry,temycmplayee.whhwagdd sh-irhale mmpcnvmet,
e work,endthe he Care Isim imendMe awed for vie(Sac.144,-we-of
and Professions CMT:The improves
Contractors License law dons ret apply if an awntt of
properl improvements remhrooar himselfa thmughhle OCC,GR UI' RES.UNI 1.9
employed,p-vdadl prove improvemwtsatamminteMTdm-ffcred(male.If,
howler will avethe burden
of pmenlnhathe did onsyear ofcmmove for the Deviser' TOTAL:
buildtt will have the M1uden-f proving that he did ret build m impasse far pugrnse of ., a
1.) ., FEB°t'7LOOD ZONE APN
❑ i.d owmrofthe propny,amexclusively contracting with licenaed<mtrvtmet i YL '^ fN•� +Y�M :lie
9n"
s Yt:y�Fn T. `1 imt{TM'/, 1 uyi•-
onstrvct the projaO(Sec.Irma,fluainda and Profesatmi Cade:)The Conuvmra PERMIT ISSUANCE
V cense l.aw does nm apply,o m ownsr of popeny w h.bui Ids m ins porn Nercon,and
whomnuecu fm such projam withacmuactte0)Ileenvd persuan1.the ConesaM, ALTER-DRAIN&VENT-WATER(FA) MARY,"
License IOW.
❑ 1 am exemp under Sac. ,B A P C for Nin masonpq
BACK FLOW PROTECT.DEVICE SANITA7'ce Y CE N
RE
Own, Data DRAINS-FLOOR.ROOF,AREA.CONO, SCHOOL? Y__N
WORKMAN COMPENSATION DECLARATION RRCEIFFN
❑ Iherclryaflmrthat lluveattrtificam-fconvnua eel!-insurc,mattnificate of FIXTURPS-PER TRAP PARK FF.E Y--N-
'-� WmkaiCmmpenvtinn lmurame on cmi0edcopy thereoflSec.JgW.Lab C.)which RECEIPT
coven ell emplayaci u`gdslhla oerdt.«� S(.�SZ GAS-EA.SYSTEM I INC.4 OUTLETS BUILDING DIVISION FEES
PalicyX NWa 'T "V est. S R.ANCHECK FEE
0 Cer.pg
GAS
❑ Certified copy is had with the
city
❑ Certified copy Va filed with the d,y inspection division. GREASP./INDUSIAL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thin eacOmneMnof he completed lfthe permit is fnronehuMml dollas(SIM) SEWER-SANITARY-STORM EA.IWFT. ENERGY FEF.
or lay.)
I canifythat in she perfonsunce of the week for which this perrelt la broad,Ishall WATER BEAT L•R WNFNTA!LF.CIA PAID
not employ any pram in any manner are as to bacteria subject to,he Work,.'
CmmRnvtionlawitaCyifmmba. Date WATER SYSTplvhTREATINO Dec ReccipX
Z Applicant
2 NOTICETO APPLLCANT:If.eftar meting this Cmifiaeof Exempla.youshould NEW RESIDENTIAL PLMIL SQ.FT, TOTAL:
I,) become.unjec,m he the Workers povlabm of, labou Code,you must BUILDING ME
�i 2: SEISMIC
comply with mach provisions Of this permWhelf he deemed revoked.
i ' TO �] SEISMIC PEE
CONSTRUCTION LENDING AGENCY
Z I hereby affirm that them is.mnswaion larding agency for The Performance of ,. ELECTRIC FEE
O thework fm which this permit le issued(See.3097,Civ.C.) _
U. .r Lidera Name -'u;: a :"•e. PLUMPING PEE
[U+ Q7'Y. ,Il`� ;+MP.CIIANICAL"PERMIT:"' +u bRE
OI<ndare Addrcv 'o. - r.... 1. Y.».•Ph';t
LSI 1 acetify that 1 have read this application and sate that the-hove In 6.1, MECHANICAI.FEE
correct.l agree to comply withal)city and county mdinamd and stem laws rcletlng to PERMIT ISSUANCE
Vy buildingconstmcdon.sad hereby authorize rcpreaenmtiver-fthiadtymmteruPnn the CONSTRUCTION TAX
,r me-meno
ntiod properly fm Inspection purpnd
r . ALTER OR ADD TO MECII.
(We)agree to save.indemnify and keep harmless the City of Cupertino against AIR HANDLING UNIT(t010,00(1 CFM)
li.bilitid,jMgme .cnsDamleapenvJ hone ywey ettrveegainauid COy
inconsequence the grey' of W/'m/yf t. O - 1 AIR I IANDLING UNIT(OVI 10,1100 CFM)
of ApplicantM ractnr 3,I ust.
Gate P.XIIAUST 110013(WIDUCID PAID
HAZARDOUS MATERIALS DISCLOSURE
I MATING UNIT(TO IW.000 BTU) Duns ResciptX
Will the due Cupertino Municipal
osle.Cantarorcu,anMhle hnvrdmnd Sated IIFATINO UNIT OVER 1W,tep Bl'U) AI.
as dcfineJ by the Cupertino Municipal Cat.Chapter 9.11,and the I le-ItM1 end Safety
Cale.Section 355720? VENTILATION PAN(SINGLE REST D)
❑Yen ❑No ISSUANC•DAT i
• BOII.F.R.COMP(71IP OR IM.0M BTU)
Will lair coinntmfumns denneg by he Day Am Air Qualitc Management
Pn� D
hvardous air rnnmminanta as defined by the Bey Am Air Quality MenagemcntMOFFIC
BTU) !` A ' V
Diarist? MAR
❑Yd ❑No .FT. I,I„a\ O
1„ 199
I have rod the hound-m matedab rcquisetnena usher Chapter 6.95 of the
California I lealth&Safety Che,Sections 25505,15577 and 25374.1 understand thatCII r l
if the building dors not currently have s tenant,that it Is my responsibility to notify the �r V'Uf Eft T j
'cupay of Om requirements which noun he met pini m Issuance a!a Certificate of
Oesupanry.
Owner m embotizod.gat DataTAL: ISSUED BY: