26560 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO UIL i- ,L A PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 5 C J UO
HUILDING ADDRESS: SANITARY NO. APPLICA'nOONSUBMITTALDATI
0 1,0 ES:ZQ76 7/.,f LOT# �1
OWNERS NA F,: PHONE: CONTRACTOR'S NAME: LIC NO:
tO i✓ a O L NBC CONTRULff
e
RCHITECT/FNGINF.ER: CN : AD RESS:
. 1 v S7
ee-
'ONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
HLDG ELECT P.UMH MECH
PERMIT ISSUANCE. ��ITY/
LICENSEDthat
nal CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL. JOB DESCRIPTION
pmZ Ihereby affmnha l 3 office sed Business and
Profeprovisionssions Code,
and
(commencing se wish
00 Semina]000)of Division J of the Business dna Profession¢Code,end my license is in ppryElS
K W ran torte and f c I.
FZL License la_s/' rl.ic. UP TO IDOAMPS
why DatCan.ECTSDr 201-1000 AMPS
Z Oy Z ARCHITECTS UECLARA'1'ION - OVER 1000 AMPS SQ.FT.R.00R AREA 5/SQ,FT.
O Z—p I understand my plans shall be used as public accords.
Z L'F; SIGNS ELECTRICAL
Licensed Professional
�yd'Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KO a V 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
W 3 a y following rectum.(Section 7031,5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
1_go�F prior to which requires u permit to entrance,alter,improve,demolish,or repair any structure
5wYits issuance,alee requtes theapplicanl for such perniuo files signed armament iPOWER DEVICES
,, C) that he is licensed pursuant o the provisions of the Contractor s License Law(Chapter
as 9(commencing with Seetion7")of Division 3 mNe Business arm Professions Cade SWIMMING POOL ELECTRIC
W M, ) ^ VALUATION
pJ Z>r or Sechat tion70cxcmpnyapplicantf the a Permit
subjealkBeEexrnant to civiny l
of OUTLETS-SWITCHES-FIXTURES
FZ_Q .... .hiL5iv myapplicantsubjects the applicanuoaCivil penalty of ...7Vw
C�pnm momthanfoeibepro dollars yempl
I,mownemflhe per y.onnyemployceawilh wugmsas lheirsolecompetssaicn, NEW RFJIUIiNTIAL ELECTR —SQFT.
p ❑ pre 1 STORIES TYPE CONSTRUCTION
a3°-2 will dothewons and the o chure isContra tors Lice derofw sal does orsaiapply to an easiness
and Professions Code:no Contractors License Law does not apply f an owner of
propertywyeca,rovi impmvesth imprandentsmessuchwod NmueredI agM1his
employees,lding r improuchlmprovomenthin noaimerdcdom eared the o nr- OCC.GROUP RIS.UNITS
ho lder w the building or improvement is hath within one year of completion,the owner- TOTAL:
builder will have she harden of proving Icor he did not build or improve for purpose of
sola). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ Las the project
(Sec cn,14,Business
and ntmcun8wwde:)The ntmeorsto
wmswm the pmjecl epee onn Raptness and Professions Cade)The Commends
ho couhwauextch pplytn a now aefofpmpeny whosed paorimprome Coacogand PERMIT ISSUANCE
whocommcts for such projects with ucontmctorts)licensed pununnitoahe Contractor's ALTER-DRAIN V -WATT Et)
License Law. a FEE SUMMARY
❑ Ism exempt under Sec. D&P C for this reeki'n II 1 v IBACKhF1.bV{PRO TE T':DEVIGE OUTSIDE Eli-S
SANITARY YN
Owner Date t RECEIPT k
WORKMAN COMPENSATION DECLARATION /' ( DRAIrySIII OR ROOIL AR ',C§N SCHOOLTAX YN
❑ Ihcreby affirm thatlhaveacenifcam ofconunuo self-insum,eracenifcaaeoL �- IiXTURES ER RECEIPI'k
rk
Woers certified co,,Insurance Orn certcopy themcf(Sec.3800,LahCJ which PARK FEE Y N
covers Polley p 1 employee's uad-this permit A I[6A5- S JI RECEIPT'0
BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVERS EA)
❑ Cmificd ropy is hereby famished. ( PLANCHECK FEE
❑ Ccnifca copy is fled with the city incpccaian division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This motion need not bea completed ifahe permit is forearm hundred dollins SURd SEWER-SANITARY-STORM HA.200FT. I?NERGY FTE
or loss.)
I certify that in the paformaneecfthe work for which this per mit is issued.)shall WATER HEATER W/VENT/ELECTR
our employ any person in any manner
soas m ecome subject 1.she Workers PAID
zCompenationWwsofCalifrmia. Dae
WATER SYSTESBTREATING Dore Rcceiptp
Applicant
z NO IICE TO APPLICANT:If,otter making this Cenificme of Exemption.you should NEW RESIDENTIAL PLMB. SQ.FT. .TOTAL
becupe
ome subject the Workers Compensation provisions ofthe Labor Code,you muse
> forthwith comply with such provisions or permit shall be deemed mocked. EBUILDINGMECONSTRUCTION LENDING AGENCY Ej7t
z Ihereby affirm that there is a conswction lending agency for the pedomance ofU the workfor which this permit is issued(Sec.309],Civ.C.) TOTAL:Lender's NameO U tender's Address QTY. MECHANICAL PERMIT FEE 1 certify that 1 have read this application and slate that the above informa im iscorrect.I agree to comply with all city and county ominances and state laws delatingto PERMIT ISSUANCE
V) pudding construction,and hereby authorize representatives admix city to enter upon the
U z above-memionW property for inspection purposes. ALTER OR ADD TO MECII. CONSTRUCTION TAX
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,coststrnd expenses whlchnaay in my way eccmeagaimt maid City AIR HANDLING UNIT(TO 10,M CFM)
in uenCe eeraming nithis permit.
G`(/, A^/L/ AIR HANDLING UNIT(OVER IO.IXJp CFM)
StFilinure of Appbwnt/Gmuactor Date EXHAUST HOOD(W/DUCn
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I00,000 BTU) Date RceciptM
Will the applicant orin furore building occupant store o.handle Invariants Health
amaterial
as defined by the Capeninn Municipal Code,Chapter 9.12,and the Heahh end Safety III-iATING UNIT(OVER IIX),()J0 BTU) L:
Code Section 25532(a)7
❑Yes 0 N VENTILATION FAN(SINGLE RESID)
BOILER-COMP(SHP OR 100.00 B ISSUANCE DATE
Will tair co lamina is a,building by duenmseequipment uality anagemech nt U)
DistNous air conwminena as defiant by the Buy Area Air Quality Management gO1LER-COMP(OVER 1 W,000 BTU)
Dislricl?
❑Yes ❑No NEW RESIDWI IAL MECII. SQ.E'. JUN
'1^r '1
1L
1 have reaham
mi the hndous mamrials darommmJUN ems under Chapter 6.95 of the 1994
California Health&Safely Code,Sections 255115,25533 and 25534.1 understand that
if the building does not curemly have a tenant,that it is my responsibility to notify the
ccupina of the royuirsmems which must be met prior to issuance of a Certifcam of I/Y Ur vvf -" I ,
Occupancy.
Owner m authorized agent Date TOTAL:
ISSUED BY:
OFFICE