26741APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING DIVISION APPLICATIONMERMIT
•... A .
PLUMBING- MECHANICAL
BUILDING PR03E(TI' IDI{NTIFICATIDN
PERMITNO.
26741
BUILDING AGGRESS:
SANITARY NO.
AAP�PLICATIIONSUBBMMITPALDATE
OF �LY
UNIT LOT#
ILII
! —
O P g NAME: PHONE:
F OC
C T}�A7R'S NAME: LIC NO:
(/�� g/1 'a V `
N/C
❑
CONTROL#
ARCHITP.CT/ENGINEER: LIC NO: IRESSI
7St l ^ .e so,*' ,"r Ar
CONTACT: PHONEBUILDING
"
QTY. ELECTRIC PERMIT -
FEE
PERMIT INFO
ELECT PLUMB MECH
TrL ❑ ❑
I�
" in . -' rt.BLDG
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
1 heteby uffiw that I um licensed under provisiom of Chapter9 (commencing with
APPLIANCES- RESIDENTIAL.
-JOB DESCRIPTION
Section 7") of Division 3.f the Business and Professions Cade, and myliamse is in
mB ruse arta erz«t.
PANELS
1
�RJ
License Closs�
UP TO 200 AMPS
Da C.nwcrm_ G�Rrr_
Contractor
ARCHfTECFS DECLARATION
I understand my plans shall be used as public records.
201- 1000 AMPS
OVER TWO AMPS
SIGNSE :72MICAL PF I' r
SQ. FT. FLOOR AREA
B
S/SQ. PT.
Licensed Pmfcssionel
OWNER -exempt R. the Contractor's
1 hereby aftlw thm I oro exempt from the Canwcmro Lew for the
SPECW.CIRNIT/MISC. , �\
following rmxn. (Section 9011.3, Business and Professions Code: My city or county
e: My
TEMP. METER OR POLE INST. -
which rcyuircs n permit to conswm, ehm improve, Demolish, or repair any swnure
primmiu issuance, elsorcquirts the applicant for such permiUo fileasigned suumrnr
POWERDEVIC85 DATE
that he is licensed p irsuenuo the Provisions of the Contractor's License Law (Chapter
9(corrmencing with Section 7")w Division 3 ofthe Business and Professions Cade)
SWIMMING POOL ELECTRIC
VALUATION
orthat he is exempt therefrom and the basis for Ne alleged exemption. Any violation ofTITLES-SWITCHES-FIXTURES
&m
Section7031.5byyapplicant fnrnp<wit subjecrs the applicant mecivil pcnehy a(
not mom than Eve hundred dollen (SAMA. -
❑ I,asownemfihepropM,ormyemployeeswithwegessstheiraolecompensadon.
NEW RESIDENTIALELELTR_SQ. FT.
STORIES
TYPECONSTRUCTION
will do thework, and the swcureisnot intended muttered forsde(Sce. 7044, Business
and Professions Code: The Commctor's License Law does not apply to an owner of
pmpmy whnbuildsarimproveathermn, andwhodenseuch work himselfor throughhis
own step loyeu, prov idcd that such improvements me nm immdedm affcrcd far sale. If,
OCC GROUP
RES. UNITS
however, the building or improvement is sold within one year of completion, the owner.
builder will have the burden of proving that he did not build or improve for purpose of
'TO k�
ante.).
❑ 1, esownerofthepropeny, amexclusively convecting with licarmA conwcmrsm
QTY.- PLUMBINGPERMIT
FEE
FLOOD ZONE
APN
orolmet the project (Sec. 70 , Business and Prof mews Code:) The Convector's
License Lawdowe a.rapply toanowmw.fpmpeny whobuildsmina,mves thereon,and
PERMIT ISSUANCE
who snnvems fm such projects with&c.nhxctortwheensed puramnt to the Commoner
License law.
ALTER - DEAN & VENT -WATER (FA)
FEE SUMMARY
❑ I sem exempt undo Sec. , B & P C for thiswon
BACK FLOW PROTECT. DEVICE
o D
SANITARY YN
RECEIPT#
Owner Date
WORKMAN COMPENSATION DECLARATION
DRAINS - FLOOR , ROOF. GOND
., .
SCHOOL TAX Y N
❑ I hereby affiw that l have o certificate ofconsem to self -insure, or a certificate of
Workers' Compensatim huumnce ora cerified copy thereaf(Sec. 3800, Lab CJ which
covers all cmployei s order this p .it.
Policy#
FIXTIIR[S-PER TRAP
GAS - EA. SYSTEM -I INC. 4 OUTLETS
RECEIPT#
PARK ME Y
RECEIPT #
BUILDINGJAVISIO F
LANCHECK FEE
Company
EICazified copy is hereby fumished.
GAS - FA. SYSTEM -OVER 4 (EA)4GIAMING
FEE
EI Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASE TRAP
OILS PEE
COMPENSATION INSURANCE
(This secdm need not be completed ifthe permit is for one rotation]dollwa($100) SEWER - SANITARY - STORM EA. 200FT.NERGor
less.)
I unify flood in the perfmmence of Nework for which this permit is issued, l shell WATER HEATER W/VENT/ELECTR
not employ any person in any mann« so as m become subject to the WorkersAID
Cao,wastun Lawsof Califomin Date
WATER SYSTEM(IREATING
Dam Receipt#
Applicant
NO' I' ICE TO APPLICANT: If.after making this Certificate of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOT
become subject to the Workers Campeasetion Provisions of the labor Cade, you must
forthwith comply with such provisions or this pewit sball he deemed revoked
BUDDING FEE
SEISMIC FEE.
CONSTRUCTION LENDING AGENCY
1 hereby M. that there is a convection lending agency for the performance of
the work for which this permit is issued (Sec. 309T, Civ. C.)
TOTAL:
ELECTRIC FEE ^�
Leader'a Nameat
-p�y�
Len lknes Address
- - MECHANICAL PERMIT
FEE
PLUMBING FE
1 unify that I have read this application and eta¢ rhm the above infowmiw is
correct.lagree meemply with all city Brut county oNinarmes and sure laws reladngm
�iikQ-.."
'
PERMIT ISSUANCE
MECHANICAL .E
building cnnswmion, era hereby amhotize rtprtsenudves of this city to enter upon the
above-mentioned xmpers, for inspection puryous.
ALTERORADDTOMECH.
CONSTRUCTION AS
(We) ugrte m save, indemnify and kap hnrmlms the City of Capetian. against
Imbilities,judgmems,coansnd expenses which may in any way accrueaguinst.0d City
AIR HANDLING UNIT (TO IgIX1) CFM)
in emm"t mea.. h granting ofteir pewit.
AIR HANDLING UNIT (OVER IB,DW CFM)
PAID
Dam EXHAUSTHOOD(W/DUCp
gnumreof Applicant/Conhacmr 10V
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT ITO 100,010 BTU)
Da¢ eiprp
AL:
Will the appfle,C.ant or ntim. Municipalng Care.
m defined by the Carecupanlsr9,ric 2, it le th, Hzallour and Safety
no Municipal Cade. Chapter 9.12, end the Health and Safety
HEATING UNIT (OVER Uay"BTU)
CMa, sari 025332(u)'!
32m)?
❑ Yes ❑ No
VENTILATION FAN (SINGLE RISID)
s 1IDSUANCE DATE
� YJ
Pis
BOILER- COMP OUT OR iM." BTU)
Will sM1eepplinntor Cut.. building«cupanmxequiptamordevices whichmit e
to mrdous air contaminants as defined by the Bay Arc& Air Quality Management
Disuim?
❑ Yes ❑ No
BOILER -COMP (OVER 100000 BTU)
NEW RESIDENTIAL MECH.—SQ. FT.
TJ UAL 191994
I have read the herando s materials requirements under Chapter 6.95 of the
California Health &Safety Code, Sections 25505,25533 and 25534. 1understand Net
if the building does not tenant,
curently have a that it is my responsibility to notify Ne
I
l urthIIIVU
;11[Y Ur
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
ISSUED BY,
Owner or ambodzed agent Data TOTAL:
OFFICE