26592 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-FILM TRI AI. PERMITNO.
BUILDING DIVISION
APPLICATIONIPERMIT PLUMBING.MECHANICAL 26592
BUILDING PROSECT'IDENTIF'ICA'L']ON
D
BUILDINGAU(/yD�RRF�S/S: .�/
2LQ,r SANITARY NO. API'LICATIONSUBMITTALDATE
V gD /yJ� w�� f L_ I UNIT# VV LOT#
OWNERS NAME. PHONE: CONTRACTOR'S NAME: LIC NO:
NPC CONTROL#
•ARCHITECLENGINEHR: LIC NO: ADDRESS:
WLI Fa"^ A� PAW ALTO
r- ❑
CQ ':� VVI UPfM PJ :ego QTY. ELECTRIC PERMIT FEE BC. BUILDING PERMIT INFO
MECH
`/ L�C11-2—,
— ELECT PL _
PERMIT ISSUANCE orri �i'p.•lr
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
nedz I hereby affirmthut l am licensed underprovisions of Chapter9(commencing with
iUCC Section]000)of Division 3 of the Business#and Propfessions Code,and my license is in PANELS
FF.g License full
Cand cffen.(Z hie.# UP T02(IfIAMPS
vFi Q a Date Camemme 201.I(KKI AMPS
%8S F RCIIITECTS DECLARATION SQ.FT.FLOOR AREA $/SQ.FI'.
0 Z-n 1 understand my plans shall he used as public records. OVER I(kp AMPS
F,yFtal SIGNS ELECTRICAL l.�-s fcJ h��J l,
4 y:,2 Licensed Professional I\J b]U(
L, < OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
xdp�OyU I hereby affirm that I ten exempt from the Contractors C's License Lew for the - -
1D3ay
following memo off,.
I was .tusinessp,to andProfessionsCale:Any e...city or county TEMP.METER OR POLP.INST.
C fJ�g which requires a permit to construct,alter,improve,demolish,or repair any sweam
Cq
priorm its issuance,also requires the applicant for such permit to rile a sigradowemem POWER DEVICES
00 that he is licensed pursm
unen to the provisions ofthe ComcmLicense Law LicenLaw(Chapter
a q.N 9(commencing with Section]OBD)of Division 3 ofthe Business end Professions Cade) SWIMMING POOP.ELECTRIC l IALLUA nQN
Wim or that he is exempt therefrom and the basis for the alleged exemption.Any violation of anOUTLETS-SWITCHES-FIXTURES jlg
yN YQ
Section 7031.5 by y applicant for a permit subjects the applicant to a civil penalty of 1 J
,more that Eve hundred dollars($SW). Q. O !GTRIE PECONSTRUCION
ZO NEW RESIDENTIAL[LECIR S FT.
C ❑ Lthe w work,and
eestructure nyemployed orofwagmasthe(Sm.compemsiness
yg2 will dorewar sandt: structure isnot intended Low does at apply 1.ar,owner
unA Rofmsinns Code:The Commaors License Lew does not apply In an owner of
pmpeny who builds or imporna thereon,and who does such work himsef or through his
own employees,providedthmsuchimprovinumatate not imendcdmoffered forsale.if, OUP ES.UNITS
however,the building or improvement is mid within one year ofnrmpletion,theowner- \
builder will have the burden of m that he did not build or improve for of TOTAL:
prov' g prove purpose
wile).
❑ I,as ownerofthe properly,am exclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEEFL OD APN
,instruct the project(Sec.7044,Business end Profasirm Code:)The Contactors
Licenaelawdoe,mam lyl.an.amerofpmpertyadr.la lds orimproves dterron,and PERMIT ISSUANCE.
who contracts 0nuch projects wills a commetods)licensed pursuanuo the Cmwaarr s ALTER-DRAIN&VENT-WATER(EA) IEC;SU MARY
License Law.
❑ 1 am exempt under Sec. .B&PC for this reason BACK FLOW PROTECT.DEVICE
SAYN
TARY
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT
WORKMAN COMPENSATION SCHOOL TAX Y N_
❑ ers'Co affirm othat lhave
rance or a cad iedoment topyther f(Sce.38,0r Lab C.)are ofwhich FIXTURES-PER TRAP RECEIPfp
Wmkeri Coployeeionlnsumntton cenifiW copy @ereof(Scc.3900.Wb C.)which PARK PF.E Y N
rsall employee's under this permit. GAS-Pit.SYSTEM-I INC.4 OUTLETS RECEIPT'M
Policy# BUILDING DIVISION PET'S
Company GAS-EA,SYSTEM OVER 4(FA) PLANCHECK FEE 70
❑ Cenified copy is hereby famished. W
❑ Cenif dc.pYis filedwith the ciryinspection division. GRIASFIINDUSTRL WASTE INTERCEPTOR GRADING ME
CERTIFCATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS IEE
COMPENSATION INSURANCE
(Thissection need not he completed ifthe permit is(atone hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or lees.)
I certify that in the performance of we work fur which this permit is scared.l shell WATER HEATER WNENTIT:LE:CTR
of employ any person in my manner so a to become subject t0 the Workers' PAID
z Cumpenmtionlawsnf Culifionn. Data WATER SYSTEMfrREATING Dam Ref in#
Applicant
zzCO NOTICE I'O APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. to AL:
[^ y become subjectto the Worker's Compensation provisionsofthe Labor Cade,you must BUILDING IEE 946
fnnhwith comply with such Provisions or this permit shall be domed revoked. sp
[� CONSTRUCTION LENDING AGENCY SEISMIC FEB I(/,Of
1 hereby uffpm that there is a concoction lending agency for the performance of
U ,Z �j
O work for which this permit is issued(Sm.3097,Civ.CJ TOTAL: ELECfRI �.�a
Leaders Name PLUMED rE
� I^ LIxnders Address QTY. MECHANICAL PERMIT' IEE
U 1 certify that 1 have read this application and state that the above information is MECI IANICA. 'E
>`" correct PERMIT ISSUANCE
Ivgrce to comply with all city andcoumy oNinancas and smelews relating to
Cis buildingcommuction,and hereby outhoricampresenmtives of this city Income upon the CONSTRUCTION AX
U above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save.indemnify and keep hurmless the City of Cupertino against
liabilities,judgment,cost and expenses which may in my way memo against said City AIR HANDLING UNIT(TO 10,000 CFM)
ce of the gruming [this permit.
AIR IIANDLING UNIT(OVER 10,000 CFM)
Signature ofApplicant/Cm moor Date EXHAUST HOOD(W/DUCf) PAID
SM ERIALS DISCLOSURE
HAZARDOUS HEATING UNIT(TO 100,0110 BTU) Data Receipt#
Will the applicant or future building receptor,mare or handle hatswims mmedel HEATING UNIT(OVER 100,000 BTU)
TOTAL:
as defined by the Criteria.Municipal Code,Chapter 9.12,and the Health and Safety
Ctle,Section 25532(x)] VENTILATION FAN(SINGLE RPSID)
❑Y. 13 No
ISSUANCE DATE
WiilNee licanmrfuturebuildin umtuse tordeviceswhichemit BOILER-COW(311P OR IW,IXg)BTU)
pp g0ec p Am.Air B� p 0 D
hazarc.as air contaminants as defined by the Puy Ama Air Quality Management BOILER-COMP(OVER 100,000 BTU) 1'� {Y
DistricR
❑Yes 13 No NEW RESIDENTIAL MECH IS I SQ.FT. -�Q N0�! 23 '$o(�A
I have read the hartrdaus materials requirements under Chapter 6.95 of the 1994
California Health&Safety Code,Sections 25505.25533 and 25534. 1 understand Nat /s
if the building does not currently have a tenant,that it is my responsibility to notify the CITY Uf
occupant of the requirements which most be met prior to issuance of a Ce tific t,of LUr U
Occupancy.
Ownwwwahori cdagem Dam TOTAL: ISSUED BY:
OFFICE