26894 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUILDL :-ELECI KICAL PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTUFICAI'ION
BUILDING ADDRESS: c SANITARY NO. IAI'1'LICAIIO/N�SUBMDTALDATI
4 UNIT# LOT
OWNER, NAME: PHONE CONTRACTORNA
'SME: LIC NO:.0,11 9
_ N/C CONTROLN
�AR I ECI'/h GINEER: LICNO: ADDRESS: ` i ❑
CONTACT: PHONE: p�_ QTY J ELECTRIC PERMIT FEE BUILDING PERMIT INFO
d 9J BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL
M=Z I hereby affirm that l am licensed under Provisions of Chapter 9(commencing with TOB DESCRIPTION
FOO Seen.7")of Division 3o1 the Business and Rofcsions Code,and my Inverse is in PANELS s �V
cac WF. full funic and c t. p
ZUVi I.icenu Class c `� I.ic.p 3s�6.36� UPT020JAMPS
y6sn Date Commcmr 201-IOW AMPS
,ZpNZ ARCHITECTS DECLARATION OVER IOAMPS
04^0 IundemmnJ my plans alrc
shall be used as public oors.dSQ.FT.FLOOR AREA S/SQ.FT.
W
E.'n l'W SIGNS ELECTRICAL
Q< Licensed professional
OWNER-BUILDER DECLARATION F.CIAL IRCUIT/MISC.
KOy V 1 hereby affirm that I anal exempt from the Convectors License Use for the
W3 my following mairm. Seetion 7031.5.Business and Professions Coda Any city or c y TF.MP.MH ERORPOLEINS'T.
which requires a post to conswd alar,improve,demolish.or repair wnurt
'Wy ;; prim to its issuance,also requires the applicant for.such permit to fl gnedsiacmem POWER DIVICES
WC�Os that he is licensed pursuant to the provisions of Ne Cont leense Law(Chapter
aK�LL 9(mmmrncing with Section l(p0)of Divisio a Busineseand Rofessions Code) SWIMMIN POOL ELECTRIC VALUATION
Sectod ion
7031.5 by Nerelromand tfr mrNe .dumJ esopplmai ton..,rivi' lotion of OUTLETS SWITCHES-FIXTURES //�� �yD
Sectione than
hY any applicant for rtnis eubjeess the epplicanuo a civil pcnalry of 19 64�
Q n0 more Thanrodve hundred
epropbills (yemp.
KFS I,mownernfNc n ,o NEW RFS DENTIAL ELECfR —SQ i3� ❑ #rope rmyemwithwagaasthe(Sec.7044,,airmssand Q STORIES TYPE CONSTRUCDON
will do shes'nou and Ncas ommuctos intended Licese Law doesed of apply)B44, weer of
,o,Pmfcssiona C01e: a CnnnaCf4ra License Law such
not apply lf owner of
rovnEwhobuildsor' proves Neon,and whodnes wch work himself Nroughhis
employees"ov cJ that such imprwementxumnos imendednroffcre forsele.IL OCCGROUP
RFS.UNITS
however,the bailJin or improvement is sold wilbinont ear m 1 the er- IOTA],
builder will have fin burden of proving shut be did not build purpose of
sale) a TY. PLUMBING PERMIT
❑ I,as mwnends epmpenY.em ex I si cly a' eased nmwcmrs Q EEE Fl.00D DONE qPN
nennel the proje (Svc.7044 B s R e nsThe Commc r
Licensel-awdeesm apply nano s perrywhobuildsorimp In. PERMITISSUANCE
whocmamas form hpmjeetawiNoc ¢v Oliven smattcZN�ntraO
License Low. , AL R-
DRAIN&VENT-WATER ILA) FEE SUMMARY
m e
❑ laxempt u er Sec &P C n Nis rws BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN
Owner Date DRAINS-IrLOOR.ROOF.AREA,COND. RECEIPT#
WO KM AN COMPIiNSA'I ION DIiCLARATION SCHOOLTAX Y N
❑ Ihcmby affirms alhavc acenificase ofvonunno ulf-in .oracenificase of
FlXTURES-PER TRAP RECGIPfp
Workers'Campen"Re Insurance ora cembed wpy Nacaf re.3NW.Lab C)which PARK FEB Y N
covers all emplo��y99e'se dr ds permit GAS-FA.SYSTIiM-1 INC. OUTLETS RECEIPT'#
Policy p JG BUILDING CIV ISION FEES
Qmtpany GAS-EA.SVSTEM-OVER4(EA) PLANCHECK FEF.
❑ CeniOed copy is be by
famished.
❑ Certified copy is file il,vLth ds q lnspcaian di vision. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPT ION MOM WORKERS' GREASE'IRAP SOILS FEE
COMPIiNSATION INSURANCE
Misuctionncedn0becompleted if Nepeork isforonehundeaddollers(SIW) SEWER-SANITARY-STORM EA.2WFT.
or Is,,.) HNERCY FEE
I certify that in the performance ofthe work for which this permit is issued.L shall WATER HEATER WDIENT/Ii1.ECfR
not employ any Person in any man na m become subject m the Workeri PAID
z Compensation Ltwsof California. Date so WATER SYSTEMI REATING Date Receipt
Applicant
� 2 NOI'[CE'10 APPLICAN'I:If,after making this Certificate of Exemption.you should NEW RESIDENTIAL PL.MB. SQ.FT. TOTAL:
(— h become subject o she Workers Comperundon provism'.1'he Labor Code,yoa must
7 forthwith comply wishauch pmvi.cionr nr this permit a hall he deemed revoked. BUILDING FEE
per. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that hem is a construction lending agency for the perfonwnce of
V O the work fur which his pemr.is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC PIKE
LT Lender's Name
O Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING ME
U 1 certify that I have rend this applustoom and state ,,,he n swe inhnmusum is
FG cored, l agree to comply with all city and county ordinances and state laws relating to ' PERMIT ISSUANCE MECHANICAL FEE
building construction.and hereby uuNomercpresentativesof this city to enter upon the
U Z above-ownlored p,n,ny her inspection purposes. ALTER OR ADD TO MECH. CONS'IRUCTIONTAX
(We)agree to save,indemnify and keep hamdess the City of Cupertino against
liuhil 'udgmcnts,cosmund expenseswhich may in any way ueagain staid city AIR HANDLING UNIi'(TO 10.000 CFM)
conseI. ce of e g of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
amus pphrn mracmr m EXHAUST HOOD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000BTN Date Receipt It
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100.000 BTU) TOTAL:
Cut Section 25532(a)?
El Yes 0 N VENTILATION PAN(SINGLE RESIO)
BOILER-COMP(31 IF OR 100.000 BTU) 119SILANCE DATE
Will the applicant
conta inrfumrcbailned b the Bay Areequa Air
muality esanagemech nt al !1 /0
h dour air comamimmm as defined by the Bay Area Air Quality Management BOILER IW,000 BTU)
strict) R
t ❑Yes ❑NO NEW RESIDENTIAL MECH. SQ.FT. C�
1 have read the huzerdoes materials requirements under Chapter 6.95 of the d ry Gr
California Health&Safety Cade,Sections 25505.25533 and 25534. 1 undersand Nos L`Fr �99s
if the building does nm correctly have a mound,Na it is my responsibility¢I notify Nm
occupant of the requirements which must be met prior to issuance of a Cendmale of
Occupancy.
Owner or auNoriud egem Dam
A ISSUED Ii Y:
OFFICE