26333APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -'USE BALL POINT PEN ONLY
CITY OF CUPERTINO • •
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING PR0JRCP [DEBTIPIC
PERMIT NO.
_ [a �]
vATION J
BUIL/DIIN%N�aG rrAAAD''DRESS::
{ 000 • vO fimPoa* ITA LOT0
SANITARY NO.
TION SUBMITTAL DATE:
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PHONE:
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ACTOR'S ` LIC NO:
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-. BUILDING PERMIT INNFFO'
EL PLUMB CH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I herebyaifloo hat l not licemodroder Arovisimairfa,mr 9(commencing with
APPLIANCES -RESIDENTIAL
LOB .ESC PTION
Sectim,7")of Division 3 of the Business and Professions Cale, and my license is in
full tome anJ effav
Llan Class U1,1
PANELS
UPTO200AMPS
Date — GO TSD
CHITECTS DECLARATION
I undemm�d my plans shell od used na publ¢ rabunfs.
201 - 1000 AMPS
SQ. FT. FLOOR AREA
E/SQ. FT,.
OYER I Wp AMPg
"
_..
SIGNS ELECTRICAL
'
Licensed Professional
OWNER -BUILD ER. DECLARATION
SPECIALMETER
I hereby o. (Se that I am exempt tram the Cessions o License law for the
following reason (Salton 7031.5, Business and Professions Code: Any city m
SRO
RPOLE.
TRMP. METER OR POLE (NST.
improve. d acture
which n+goira u permit ro tortru to eller, improve, demolish, fi repair any strucmm
permit m ectionernarrilLaw(CIOp.,
primessioemnot,numu esismo
POWER DEVICES
inif he License
Nat he is li<rnsd pursuant m the prmvuimna of the ConnactOrs License Lew (Clupmr
tothi to
'9(commrncing with Stenion]OW)oy.ivision7of the Business and Profeuiona Code)
or that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a Permit subjects be applicant to a civil pendty Of
SWIMMING POOL ELECTRIC/s
Illrrr��a �s VALUATIIO�N
ETS-S HES-FIXTURES
fflmNEW
not mare Nan metiso a rodny,a myeW).
❑ wneroddthemerny,mmyemployees he (Sm. mUt
R ELECTR _SQ. FT.
STORIES
TYPE CONSTRUCTION
Buadon,
(m We (Sm. a4, Business
othe and the structureisnot, offeealfor
will do
fework, to
LiceeJe Law
and Professions Code: The tremon. License Lew doer not apply lf os owner of
es, is
progeny who buildsorimproves Nerton, and whodcesauch workhimselforthroughhf.
intenddord(ered fmrole. r.
ding or Nassuchim ismid within
balding
budder .Nemec, a burden of pmcntishat he id oneynr or improve farird, thebuwna-
builder will have rhe bunlrn of proving that he did nos build or improve for purpose of
❑ I,osbuwnerm(Ne pmpenY, rnsexclusivdY cbunvactingwiN licensd conmacmmm
OCC. GROUP
ZONE
RPS. UNIT'Shmov
APN
/ OT
QT PLU DI T - FEEPLOOD
conswc, the project (Sec. 7044, Business and professions Cod )The Cmumunsra
Licenx Law dcesnm apply munowncrofpropeny whobuildsorimproves Narcan,end
P AN
who contmcm fbursuch projatswiNscontmcto(i) hicmad pursuant to the Connectors
License I.aw.
❑ 1 ten exempl under S<c. . B & P C fm Nis ruaon
TER - D ENT-WATER(BA)
FEE SUMMARY
BACI(XO RO lICE
S
SANITARY YN
DamDRA
OOF,AR C ND.
RF.CEIPTM
Owner
WORKMAN COMPENSATION DECLARATION
] Ihereby affirm that l have a certificate ofconscm to self -insure, ma cerifiateaf
orkeri Compensation Insurance ora cenified copy thereof(Sco. 3800, Lab C.) which
SCI{DOL T'AX YN
RF,CC•I X
FIXTURES R
PARK FEE Y N_
R IP p
GAS - Ea. SYS -1 INC.40 S
BUILD( (VISION FEES
covers all employees under this permit
o
Company
GAS - FA. SYSTEM -OVER 4 (EA)
PLANCHEC
❑ Cenifid copy is hemby famished.
❑ Certified copy is fill with the city inspecdbun division.
GREASEJINDUS ASTEI R 'O
GRA G
GREASE TRAP
IL
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
CHus ste1i0naed not heampletd B dvc porrit is far. hundred doll.(EIfO)
SEWER -SANITARY -A. 200FT.
!L
ENERGY FEEro R�
or less.)
I certify that in Ne peRormana of the work for which this permit is ismd, l shall
not employ any person in any marmer w as to became subject to the Workcra
Compensiumn Lawsaf Califomia. Dam
WATER HEATER W/VRNT/ELECIR se
PAID
Dam Rec p
WATER SYSTEMIMPATING
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL: '
Applicant
NOTICETO APPLICANT: If, after making this Certificate of Endaption, you should
become subject to the Workers Compuda6on provisions of the Labor Code, you most
forthwith comply with such provisions or this permit shall an deemd mvokd.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affum that them is a construction lmdding agency for the perfmmence of
the work for which this permit is issued (Sec. 3097, Civ, CJ
Lenders Name
TOT
.. -��
QTY. p>" 1A LPBRMIT PE8
s�`
ELECTRIC FEE
PLUMBINGEEE
Under'a Address
I teddy that I have red this application and sum that the above infomtetion is
y pp
building tocomply hembyiathod countYorsfives sand statelaws relatingm
buildingamvuction,and hereby euthmize reprcaenu0vw of Nie city mantes upon Ne
above-mentioned property for inspection purposes.
'
PP. IE
MECHANICAL FEE
ALTER DD TO MECH.
C STRUCTION TAX
(We) agree to save, indemnify and kap harmless the City of Cupertino against
liabilities,judgments. cosh adexpenxswhich may in any way accr ageinstsaid City
AIR HANDLING UNIT CTO IL" CFM)
AIR HANDLING UNIT (OVER IO,000 CFM)
in conse9 eta oflh ting Of this pednit.
-i
PAID
Dam Receipt #
E%HAUST HOOD (WIDUCIT
Sig mreof AMM tnUContrnam Date
HAZARDOUS MA IALS DISCLOSURE
HEATING UNIT (TO 1010. 0 BTU)
HEATING UNIT (OVER IW,OW BTU)
Will she applicant orfutum building occupant stere Or handle heamdous materiel
and Safety
as defined by the Cupedino Municipal Code, Chapter 9. E2 end the HW union
TOTAL:
VENTILATION FAN (SINGLE RESID)
Code, Section 25532(a)7
❑ryes ❑ No
ISSUANCE DATE
BOILER- COW(3HFOR)W,fIW BTU)
lk-Will Ne appliannor(umm builJingcecupamuseequipmem ordevicea whichcmit
dote air comaminenm as defined by the Bay Arca Air Quality Managemem
BORER -COW (OVER I W,000 BTU)
n dP
NEW RESIDENTIAL. MECH.—SQ. IT
El Yes C3 No
I have read the hamrdous materials requirements under Chapter 6.95 of the
[
California Health & Safety Code, Sections 25505, 25533 and 25534. I understood that
if the building dos mat cuncmiy have u tenant, that it is my responsibility to amity the
MCupunl Of the requircmems which must be met prior to issuvme Of a Ccrtificane of
L 141994
�rfr�
,
X
OeNpuncy.
' rl
ISSU BY:
AL:
Ownermlimhmisedagem Date