26585 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY it
CITY OF CUPERTINO ImraimG-�-m nuc-Al.
PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MF.CHANICAL BUILDING26585
BUILDING PROJRCI'1❑RN'IIFICA'I'ION
BUILDING ADDRESS: cam+ !'Tys�` ,
Tp-
O�f["'1 t1 �y.�] SANITARY NO. APPLICATION SUBMITTAL DATE
2 C J V ta � UNIT 1 lJ ��C Lora
l�/
OWNERS NAME: PHONE: CONTRACTOR'S NAME: LIC NO: NIC CONTROL Is Sal" f T
ARCHITHCT/ENGINF-ER: LIC NO: ADDRESS: ❑
rn CAAA( t rQ R✓L isPv9 Q(ZO
•coNTpCr: 1 ' p 1?: BUILDING PERMIT INFO
� / !S� �— QTY. ELECTRIC PERMIT FEE
l BLqG EIECTMECH
B) LZ PERMIT ISSUANCE
LICENSED CONTACTOR'SDfpppLIANCES-RESIDPNTIAL
TOB DESCRIPTION
Oyz Thereby effn that amlccnsed underprovisions ofChpw9(commencing with
�00 Section)00f)af Division 3 of the Businessruidd-aPacescions Cade,and my license is in PANELS
~<5 Dates.Cl dcifect. Lie.a SZ�2 � UPT020JAMPS 5 ,
= 201-1000 AMPS SQ.PT.FLOOR AREA $ISQ.FT.
Z~Oy3 ARCHITECT'S DECLARATION OVER 1000 AMPS
CZ-0 I understand my plans shall he used as public records.
<yW SIGNS ELECTRICAL r�1f-.� 83 ��
,`Ij Licensed Professional t Jb/
vC OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC. y
OyU I hereby affirm that I am exempt from the Contractafs License Law for the �-[W
W LLOyon]O3L&a following reason, Business and Professions Cade:Any city orcounty TEMP.METER OR POLE INST. LJ I
m J which requires a Permit construct,Wer,improve,demolish,m repair any structure
act prior to its issuance.also recourses the applicant for such permit to file reigned statement POWER DEVICES
ty O0 that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
6601
09(commencing with Section 7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELTR
ECIC 1I L-1-
VALUUATION
X:y or that he is exemp 1heefrnmund the basis for lhealleged exemption.Any violationo( � �
I-ZQ Section 7031.56yasp
nyplicvpermitm C
m tura subjects th.,dicant
OUTLETS-SWITCHES-FIXTURES l a civil pimmyrif ll
not more than five hundred dollars(5500). NEW RESIDENTIAL ELECTR S PT.
ME
p ❑ I,azuwn<ropheprolmeny.ormy<mployeowith wagesaztheirsolecompenseuon, Q' O .� STORIES TYPECONSTRUC ION
x320 will do the work.and the structure is not intended or offered for Me(See.]044,Business
end Professions Coda.Me Commctur s License Law does not apply m an owner of
property who buildsorimproveadercan,and who does such work himselfurthrough his OCC.GROUP RES.UNITS
own emplogees,prosided that such improvements auction intensichoroffiermforsele.If,
however,the buildingor improvement is sold withinone yearofcampletime,the owner TOTAL:
builder will have the burden of proving that he did not build or improve fm purpose of
xCle) QTY. PLUMBING PERMIT FEE Fl.GODZONE APN
❑ Las the project
(Sroprny,tars. inesa and
Pieactderm onle:) re Comacmrsto
comwn the project(Sec.]pd4,Business and Profession.Codcq The Conuocmr'e
License law docs not apply man ownmafproperty whobuilJsorimpmves[hereon,and PERMIT ISSUANCE
who concerns for such projectswith a commas (e)Iicenscdpurmanttmhe Contrectnes
License Law. gL'T13R-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE S •E S
SANITARY Y_N_
Owner Data DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
40, ❑ Thereby effiem lhetl have accrtificne of<omsenun selLinsurc,or ncertificam of pIa LURES-PER TRAP RECEIPT#
Workers'Compensation Insurance or v certified copy themof(Sec.380.Lab C.)which PARK ME Y N_
covers all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETSRECEIPT N
Policy# BUILDINGDIVISION FEES
Company GAS-EA.SYSTEM-OVER 4fE ) PLANCHECK FEE
[ICmufledeopyisherehyfumiahed.
❑ Certified copy 6 filed widen Brevity inspection division. GREASWINDUSTRL WASTE INTERCEPTOR GRADING FEE Z•V a/
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASCTRAP SOILS IE,
COMPENSATION INSURANCE
(Thissection lament be completed ifthc permit is faro..handled dollars(SIM) SF.WER-SANITARY-STORM FA.200FT. FNI!RGY FEE � sop
I employ
an et in the performmre of the work for whiche subject to theWIkers WATER HEATER WryfiNT/F.LECIR
not employ any person in enY manner to az to became subject to the Workers' PAID
Compermsuion Lowe of Celifomia. Date WATER SYSTEM?BEATING Uvm eccipt#
Q z Applicant NEW RESIDENTIAL PLMB. OTAL:
NGTIDE'I'Q APPLICANT:If,after making this CcrtiCertificateof Exemption,you sho6 SQ.PI'.uld 1 a�
F p) become subject to the Worker's Compensation provisions ofthe Labor Code,you must BUILDI E• TICa . forthwith comply with such propermit visions or this peit shall be deemed revokd. Ik e
0. Q CONSTRUCTION LENDING AGENCY TKCFF.E
I hereby affirm that there is a consuuction lending agency fm Ne performance of
D Z TOTAL: �l EL IC E
U O the work tar which this permit Is issued(Sec.3097,Civ.C.) - 1
Lender's Name PLU 'i
O F Lender's Address QTY, MECHANICAL PERMIT FEE
U I certify that I have reminds application and slam that the above information is MF.CHANICA FEE
�" Da carred. Iagree es comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE INJI foes
f•' building coouniGiomand hereby amhodze¢preamustiveaofthis city memmrupon the CONSTRUCfIONTAX
VZ venae-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liebilitie. talgmems,costs and expenseswhichmay in any way oceme against said City AIR HANDLING UNII'(T010,000CFM)
,orSe of the greatin of Nis Planar.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Applicant/ and Dare EXHAUST GOOD(WIDULTI PAID
HAZARD fATER1AIS DISCLOSURE HEATING UNIT DO 100,000 BTU) Date Rceeiptp
Will the applicant or future building occuprom store or handle hazardous material
as,defined by the Cupertino Municipal Code,Chapter 9.12,end the Health and Safety HEATING UNIT(OVER 1(1(1,0!10 BTU) TOTAL
Cade,Section 25532(o)T
❑Yes ❑No VENTILATION FAN(BINDLE RFSID)
ISSUANCE DATE
Will theepplicantorfvture buildingoceupent useequipmentor Jevlceswhich emit I BOILER-COMP(3HP OR 100,000 BTU) 1�q
hueardous air contaminants as defend by the Bay Area Air Quality Management BOILER-COMP(OVER 10.(100 BTU) P A 8 D
lei District?
❑Yes 0N NEW RESIDENTIAL MECH. SQ.IT l 1 s1 NOV 23 199
1 have read the huzyrdoes mutedals requirements under Chapter 6.95 of the Ia7a�4
Celifomia Health&Safety Code,Section,25505,25533 and 25534. 1 amended that /�
if the building does not curtcntly have a tenant,that it is my responsibility to notify fee Ci1Y Uf LCfp...)( \
occupant of the requirements which must be met prior to issuance of a Cea fate of •Y//Yf�l�(/
Dec.,.,.
Downer or amhonud agent Dam TOTAL: t � ISSUED BY:
OFFICE