26367APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO 6D7L - 'RICAL
RUILDINC DIVISION APPLICATION/PERMIT PLUMPING -MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMIT NO. 26367 w w
'LJ hV� "V�!
BUI�GADO SS��Sro � �Re UNITp LOTp
SANITARY NO.
APPLIGTION SUBMDTAI.DATE
OWNERS5NAAME: PHONE:
`11S ,L4.M—O OO
CONTRA OR'S NAME LIC NO'.
NIC
CON'I'ROLN
,C ITECIEN NE ^r LIC NO:
V
ADDRESS:
CONTACT: PHONE.:
EL2CIRIC PERMIT FEE
BUILDING PERMIT INFO
LGO ELECT PLUMB MECH
El ❑
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm tat l am licensed underprovisionsor Chapter9(commenting with
APPLIANCES -RESIDENTIAL '
- 1OB DESCRIPTION
Section 7000) of Division 3 of the Business and Professions Cade, and my license is in
PANELS
full force and effect.
License Class Lie.p
UPTO200AMPS
—� V`JK�V
Data Contrenar
-- _ Av
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records.
201 - IOW AMPS
SQ. Ff. FLUOR AREA
$/SQ. FT.
OVER ION AMPS
SIGNS ELECTRICAL
Licensed Professional
OWNER-BUILDERDECLARATION
SPECLLL CIRCUIT/hllSC.
1 herby affirm to 1 am exempt License I.A. for to
to Cosions
'
TEMP. METER OR POLE MST.
fallowing reason. (Section ss an
Business Co county
Cade: Any city
to construct, improve, s
ve, demolish, npatr ed twcwx
which in hate u permit re comtrum, deer, improve, demolish, file
teapplicanlfor
Prior to i. issusn«,elsont
POWER DEVICES
that he is licensed pursuant to Ne provisions of the Contmcmre License Lew (CTupmr,
to the thesuch CpemdUo Licese Law
9(mmmencing wit Section 7000)a(DivisionJoflheBminesaed Pmf.sions Cade)
SWIMMING POOL ELECTRIC
VALUATION/1�
tor he is exempt therefrom and to basis fmtedleged exemption. Any viobdonof
Section 7031.5 by any applicant for. permit subjects to applicam I... ivil penalty of
�a V��
{...� J
OUTLETS.SWITCHES- FIXXTURES
not more than five hundred dollars (SSW).
❑ omown rive
ny,or S50T.oyeawit wagcsuteirxlecoty m
NEW RPSIDENTIALELECTR _SQ. FT.
STORHIS
TYPE CONSTRUCDON
win dotesimas
h LJ
not apply �yp v , if
and Came: a Contisnwbmndaderarwdoesnot a
obu Code: The Contractor's License Lew
propPo,erty wh uch
pmpeny who builds nrimpmveetherton.and whod..suchwohhimulfortmugh his
cmploebuildovided f.
ouofcmorfered
yC!;OUP
%`/��g'l
RFS. UNITS
TOTAL:
provehimprovememsarcne
theow.lr.
or improvement sold within one Lem or improve
however, to haveomm a for theowner-
builder, will pave to burden of proving tat he did twt build or improve for puryme of
the
JL
sale.).
❑ I,mownerof the pmpeny, ata exduxivelyconvxting wit licensed wmmetars to
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
APN '
construct the project (Sec. 7044, Business and Professions Co&:) The Conuacmra
License Lowdoes not apply to an ovacrofproperty whobuildsmimprovestereon,and
PERMIT ISSUANCE
whocomrsws fro.uchpmjecb witaconrrvctw(O liuvd,ousunsto to Canvacmr's
License Law.
AU.pER GRAIN &VENT TER(EA)
FERSUMMARY
❑ 1 am exempt under Sec. , B ffi P C (or this season
BACK FLOW PROTE . DEVICE
OUTSIDE .S
SANITARY Y N
RECEIPT
Owner Date
DRAWS - FL . ROOF, AREA. COND.
WORKMAN COMPENSATION DECLARATION
SCHOOL TAX YN
I hereby affirm that l have a certificate ofconxnt to self-insum, or a certificate of
wkets'Comparsation Insurance macenifid copy terenf(Sec. 3800. Lab C.) which
coven all employ.'. under this permit.
Policy p
RECEIPTN
Fl -PER TRAP
PARK FEE Y N
CEIPI p
GAS - EA. SYSTEM -1 INCA dkulwBUILDINIJ
NTVISION FEES
Company
AS - EA. SYSTEM -OVER d
IILANCHECK RIE
❑ rrrtined copy is lxrcby rmrdtd.
GR SEANDUS WA TE RC
GRADWGFEE
❑ Certified copy is Bled with the city inspection division.
GREA TRAP � J
SOILS FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
' COMPENSATION INSURANCE
SEWER- NITARY- RM .2
ENERGY
(This section need not be completed ifthe permit is Intone hundred dollars($RgR
orlen.)
WATER IIFA •R W/VENT/ELECIR
Icertify.h.h. teper5.c,eofteworkfimwhich tiapermilis Maxed, I shall
not employ any Person in any manner so m to becwne subject m the Worker%
PAID
Compemmoso Lswaof Califwnb. Date
WATERSYS EATING
Dme Receimp
Applicem
NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should
NEWRESIDENTIALP SQ. FT.
TOTAL:
become subject to the Worker's Compemation provisions of the Labor Code, you most
forthwith comply with such provisions m this permit shall be compact revoked.
BUM NG FEE
SEISMMCFEE
CONSTRUCTION LENDING AGENCY
I hercb which t t Permitcool (Sm.3 W7. Civ. C.) fm Ne perrwmence of
the wok for which this permit is issued (S.. l09]. Civ. CJ
TOTAL:
ELECTRIC FEE
Lender's Name
'" `
QTY, - MECHANICAL PERMIT PEE
PLUMBING FE
Lenders Address
I unify that 1 have read tis application and sum tat to subove information is
e meet. l agree ro comply with all city and county ordinances and state laws relating m
�
PERMIT ISSUANCE
MECHANICAL F.
haddingeonsmetian, and berebyamhndso..... ativesmfld.city wern.upon the
ahove-mentioned property, for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTI TAX
AIR HANDLING U1,17 OPO 10,000 CFM)
(We) agr. m anus, i ify and k. less to Ct of Cupertino agairet
Ilabilities.judgments,cas an xpe hmsuy in a accrueagai it said City
wit.
AIR HANDLING UNIT (OVER 10.000, CW)
consequence of to 'Sof i
EXHAUSTHODDIW/DUC)
PAID
Signature of APPlicanV' rte r Da
HEATING UNIT (TO IN." BTU)
HAZARDOUS MATERIALS DISCLOSURE
Umr, Receipt
HEATING UNIT (OVER IOO,WO PTU)
TOTAL:
Will to applicant or furore building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and to Health surd Safety
VENTILATION FAN (SINGLE RFS1D)
Code, Section 25532(a)1
Cl Yes ❑ No
ISSUAN DATE
Willthcapplican.orfotos buildingarupmtuveequipmem ordeviceswhichemit
BOILER - COMP (JHPOR I00,000 BTU) �
�/9 [k S
('9
apards as defmd by tA. o Bay AAir Quality Management
ecodou¢ aW eommi
BOILER - COMP(OVER 100,000 BIT)
Iimcr] ❑ Yes ❑ No
I have red the hvardaus materiels nquixmems under Chapter 6.95 of the
Cdiromh Health & Se(ery Cde. Sections 25505, 25533 and 25534, 1 understand that
iIthe building does nm currently haven tenant, that it is my rtsponsibilitymnotify to
��� 199/q�
I ser uurrry
NEW RESIDENTIAL MECH.—SQ. FT.
-
of the ruiremenb which must be met prior to issuance of a Certificate of
occupam ry
Occupancy.
ISSUED BY:
Owner or.m canied.gem Data
TOTAL:
urru:t