26573 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO me A. PERMII'NO.
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING-MECHANICAL. 26573
F'BUILDING PROJECT IDEN'I ICXOON
BUILDING ADDRESS:: C g/�I�� SANITARY NO. APPLICATION SUBMITTAL DATE
l `+ egar P4 UNIT# LOT. I 1__
OWNERS NAME: seses PHONE: CONTRACTOR'S NAlME: - LCNO: NIC V CONTROL is
Ca
�ARCHITEC'UENGINEFR: LIC NO: ADDRESS: 5 ❑
TY) nc IA Avu, .naw ACO
CON (ttlpl/ QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
L+�IrI, ( 1 4 -7 B � PLUMB 11
'1 01E/, PERMIT ISSUANCE �� (KUM
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
n9z I herebyieffinn that l mar,licensed underpmvisions of Chapter9(commencing with
1400 Section 7000)of Division ofthe Business and Professions Cie,and my license is in PANELS
es �snw
full farand effect. �s/r� r"
F�,W License Clps�s.�—Lie.. UP TO 200 AMPS
mj z Dem Conduct., a ^-� 201-1000 AMPS SQ.FT.FLOOR AREA S/SQ.Ff.
zc 1 — 11•"/ UsAkCHITECTS DECLARATION OVER 1000AMPS
0 z_C 1 undersand my,tuns shall themed as public moms. 875, 402,
JJ /�
root SIGNS ELECTRICAL 1_IVol 7• W2,
Licensed professional
OWNER-BUILDER DECLARATION SPECIALCIRCUff/MISC.
Rx'0OQ. 1 hereby affirm that 1 am exempt form the Contractors License law for she J
:"-y following name,(Sermon 7031.5,Business and Profcasioan Code:My cityar county TEMP.METER OR POLE INST.
C o._j which""mines a permit m construct,alter,improve,demolish.or repair any structure
W prim m its issuance,also requires the applicant forsuch pammimfileasignednammens POWER DEVICES
9!,Qpp this he is licensed pursuant m the provisions of she Conuacroe's License Law(Chapter
9(commemcing with Section 70(1 Division 3ofibe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
y��ro or that he is exempt therefrom and the baaisfor the alleged exemption.Any violationof OUTLETS-SWITCHESFlXTIIRES
z Q Section 703 LS by any applicant for a pemdt subjects the applicant to a civil penalty of - s7 L�
fit] not mom than rive hundred&Iters(5500). .
C C3LmRh
ownerneproperty,ormyemployeeswit wages as theirsolecom NEW RESIDENTIAL ELECfR 5 Pf.,amp000n, Q CV-33 STORIES TYPECONSTRUCHON
y will dm Newms Corte he Cipisnmimm�ense Law does r at apply.7n 44,Business
and Pity v h ons Code:The ves tmcson, ndwho Law does not apply lf an owner of
ownenywhmb,pmvii improventhe pmvmmts notihwnrkhroffe nhroughhis .OROfIP RES.UNI IS
hoemployeesildingdedtmmcMmprovemsold within meacrafcomplecred theownr-
wever,thebuildingburden
of pmemishatheidnot build or improve
fortrpose of TOTAL: �•
builder will have the burden of proving that he did not build or improve for purpose of
vele.). QTY. PLUMBING PERMIT FEE \ ZONE APN
❑ I,ns ownerofthe pmpeny,am exclueivelyamruding with licensed wnwaom to
crusade,the project See.7814,Business and Professions Cade:)The Cmurnevies PERMIT ISSUANCE pp
License Law does not apply man ownernfproperty whabuildamimprovestherton.and y7i
who contracts ter such projects with o contracmm(e)licensed to the Contractor's ALTER-DRAIN&VVW-WATER(EA) FEE SUMMARY
Lt...Law.
❑ 1 um exempt under Sec. ,B&P C for this reasonI,..
BACK FLOW PROTECT.DEVICE SI F
SANT Y Y
Owner Date RECEIPT p
DRAINS-FLOOR,ROOF,ARG,GOND.
WORKMAN COMPENSATION rid DECLARATION SCHOOL TAX I N
ISI • ❑ Ihembyafnamtn Insureaaniricmeof cm,thereof(Sec.
ISM,
as C.)which
FIXTURES-PfeR TRAP RECEIPfN
Wohere'Compensmion Insurance or certified copy thereof(Sec.3800,Leb CJwhich PARK FEE YN_
covers all tard.,ae's under this permit GAS-G.SYSTEM-I INCA OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYS TEM-OVER4 GIA) PIANCHECK FEE
❑ Certified copy is hereby furnished.
❑ Certified copy is riled wit the city inspection division. GRG$E/TNDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE 'A �`
(This section need nosbecomplimid ifthe permit is prime hundred dallara(SIOB SEWER-SANITARY-STORM EA.200M'. ENERGY FEF. WxVV
or less.)
I certify that in to performance of the work for which this permit is issued,I shall WATER HGTER W/VENTA3LECTR
not employ any person la any meaner an as in become subjeet to the Workers' PAID
Compensation Lowsof Celifomia. Dem WAMRSYSTEM/IREATING Date Receipt.
07 z Applicam l +�
G O NOTICE TO APPLICANT.lf,atter making this Certificamof Esempdon,you should NEW RESIDENTIAL PLMB. SQ.FT. OSs y TOT
F-' (A becomesubject to to WoskeTa Compenadion provisiersoflhe Labor Code,you must
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE 3$
a Q
CONSTRUCTION LENDING AGENCY SEISMIC PEEon, I
I hereby affirm tat mere is a construction lending agency for performance of
z TOTAL: ��,33 ELECfR E y-
I U O how ork for which ties permit is issued(Sec.3097.Civ.C,)
Lenders Name
U. LenJeeaAddress QTY. MECHANICAL PERMIT FEE PLUMB F . 33
1 amdfy that 1 have read this application and transition to above information is MECHANICX.FEE
r1'
correct.l agree mcomply with all city aped county ordinances and sae laws palating to PERMIT ISSUANCE • >
F^ n' huildingemsuuction,and hereby authorize representatives ofthis city to enter upon the
fA CONSTRUCf10 AX
V z abov(We)igree,saws, for inspersion purposes. ALTER OR ADD TO MECI1.
I We)agree n save,indemnify and kap himmay in any
the as a of a against
s at City
rest
liabilities,judgmenls.arses and expenses which may irony weyeccruc against said City AIR HANDLING UNIT(TO 10,000 CFM)
in canypuey"a—of she gmndn a G I7!}�I
AIR HANDLING UNIT(OVER 10,00)CFM)
Sigmmm of Applicant/ ommrsof Ilam EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE I IEATING UNIT(TO 100,00 BTU) Date Re ipt#
Will the applicant or future building escapism stem or handle hmardous material HEATING UNIT(OVER 100."BTU)
as defined by to Cupertino Municipal Cole,Chapter 9.12,and the Health and Safety
Cade.Section 25532my1 VENTILATION FAN(SINGLE RPSID)
❑Yes ❑ No
ISSUANCE DATE
WillteappliemlorfutumbuildingwcuWtumeuipmcnlordevicawhichemis BOILER-COMP(311POR 100,000 BTU)
P AD
hazadconfirmation,s air confirmation,to defrad by the Bay Aru eAir Quarry Management BOILER-COMP(OVER 100,000 BTU) B
District?
❑Yes ❑No NEW RESIDENTIAL.MECH. SQ.FT. tp5�^a36 NOV 2 3
1 have read the Indications materials requirements under Chapter 6.95 of the 1994
California Health&Safety Code,Scaion9 25505,25533 and 25534tracer,tracer, undersand mus V ry f.VF 1
if the building does not currently have a tenthus it is my responsibility to notify the V^, ( L"'C„I'F .
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy. rf 2
Owner or eutodmdugepn Date TOTAL: 1,31 s J ISSUEDBY:
OFFICE