26302 APPLICANT TO FILL IN INFORMATION.WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-JKLE 'FRT AL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 26302
BUILDING DIVISION NUILIIING PROJECT IDP.NI'IF-ICA'I'!ON
PRIMING ADDRESS: � � SANITARY NO. A'PP'LIICATIONSUBMITTALDATE
e)2ro UNIT# LOT# - � G
' CONTRACTOR'S NAMELICNO:
TAL
N/C CONTROL#
ZG
T /EN` HR
LIC NO: ADDRESS:'w, �t `r ❑
F}, 440 W — J 3�4 X11 b
CONTACT: PHONE: .
QTY. ELECIAIC PERMIT FEE 6UILDING PERMIT'INhO
1�(xTa,�"ty4 BLOC/ ELECT MECH
PERMIT ISSUANCE � ,1C7Jr(_
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDE TAI. k. JOB DESCRIPTION
pC2, I hereby affirm that l am licensed under provisionsoft7hapmr9(commencing with
µ100 SvcR a7")afDdvtsi Sof the Bnsinaeand Rofeuiom CtWe,and my license is in PANELS
6a UU CCGGJJ f_zkuull farceort el'fe
License Contr DP'I'G (IIIAMPR
1/
m „� nate contractor 201 ❑ rs -
ZON� ARCHTTBCI-S DECLARATION OV 3P5 SQ.R.FLOOR AREA SISQ.FT.
OZ-0
p 1 underntvtd my plans shall he used u public reeoN.s. ` tr
F-y Licensed professional SIG H CAL, 1 W
��uau11
OWNER-BUILDER DECLARATION SP CI CUTT SC.
C:U 1 hereby affirm that 1 am exempt from the Commands License Law for the
31r-F following teases.(Section 7031.5,Business it Professions Code:Any city or county :M MI?I'BR OR POLE INsT.
which requires It permit to construct.alter,improve,demolish,or repair any.Moue
22}2 primtoiRi....ace,also requiresthe applicant for such pern;uo file.signed statement POWER DEVICES
Cap that he is licensed paruatn to the provisions of the Commences License Law(Chapter
Lyo6' 9(commeneing with Section 7")of Division 3 of the Business and Professions Cale) SWIMMING POOL ELECTRIC �1 VALUATION
W_w or that he is exempttherefrom and the basis for Ne alleged exemption.Any violation of OUTLET'S-SWITCNPS-PIXTORES 1'ZC /2/�Als
>
Section 7031.5 by any applicant for a Jambs subjects the applicant m a civil Firm of z,(-` V
not more than five hundred dollars($5(10.
e ❑ I,asownaofthepropcny,ormyempdoyeeswithwageamtheirsolecompensation, NEWRISWENTIALBLECTR —SQ']-T. STORIES 9'YPFCONSTRUCTION
x300 will do the work,and the smucmre isnot intended arnfferWforede(sEsiness
end Professions CnJe:Th<Contrumra hittnu Lew does noMyna. runof
property who buildsorimproves thereomand whodues a mkhimsdforth ehhis
ownemployeca,providedthat each;mprovem of intended mothered fors Is,If. OCC.GROUP RES.UNITS
however,the building ori odwithin one yeurofcompinion,then mer- -�
builder w it l have the bu Jen of proving the he did not build or improve for puHx onT FITZ
sale.).
❑ Lasownerofinep pony,amexclusivelycmn ctingwitblice.aW m ,t In QTY. PLUMBING 11I7RMIT FEF, FLOOD ZONE APN
tstnta the project IS .704L Business and easionF Ae:)The Contra, is
License Lawdmanmappl marrow e,.fp,.,nywt6r tmprevesthereon, d PHRMITISSUANCE
wheamsforsuch pori Basi emit li ism n
aothe mme
Conts
Licensence Law.
ALTER-DRAIN&VENT-WATER FA) FI7E SUMMARY
'❑ I am exempt Maier Sec. ,Il& C* ix rtMen BACK FLOW PROTECT'.DEVICE OUTSIDE FIRMS
SANITARY YN
Owner a •RECF.IPTp
WORKMAN O EI Off' ATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOLTAX YN
❑ Thereby affirm thmlheve cenifiu 2onem malGinsurt,o em state of RF,CEIPI'p
Wohers Cnmpestsabon lnsumn Decent sed copytheree((See ,Lab CJwhich FIXTURES-PLR TRAP PARK FEE Y N
covers all employee's under this Pit., GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy#- BUILDING DIVISION FF.IiS
Company GAS-FA.SYSTEM-OVEN 4 EA) PLANCHI3CK FEE
❑ Certified copy is hereby fie dshcd -
❑ Comfied copy is fled with the city inspection division. GREASHINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOELS FEE
COMPENSATION INSURANCE
(This section n,ednol be completed itme Kmtir is porch,hundred dollms($100) SEWER-SANITARY-STORM EA.20aFT. ENERGY FEE
or less.)
I cenf"I'm dacha pertom.anc,nfihe work for which this permit is issued,I shall WAIER I FL'I'ER WNRNT/HLECTR t
mot employ wI,person in any manner an as to become subject to the Workers PAID
Compemmionl.uwsof Calimmi.. Dam WATER SYSTEM?BEATING Date Receipt
O z Applicator
Z 0 NOTICE TO APPLICANT:If,mAcr making this Cenificate of Exemption,you should NEW RCSIDENTIAL PLMIL SQ.FII TOTAL:
V) hecome suhjcn to the Worker's Compensation provision nftha Labor Code,you must
a + forthwith comply with such provisions sir this permit shall be deemed revoked. BUILDING FEE mar
aQ CONSTRUCTION LENDING AG I?NCY SEISMIC FET? D
V z 1 hereby uffrm that there is a conVatioh lending agency for the performance of -
Npermit e work for which this peit is issued(Sec.3097,Civ.C.) ELECTRIC FEF
Lender's Name
OF lender's Address QTY. MECHANICALPERMIT FEE PLUMBING FEE `
U 1 certify that 1 have most this application and suite that the above information is MECHANICAL FEE
corer,. Ialimemenmply with all cityanJtoumy commancesundstme laws relutiogm PNRMI'I'ISSUANCE
buikIm,,M,Ractinn,and hereby nulboriu represemativea of this city to enter upon the - CONSTRUCTION TAX
(J '/ above-mentioned propmy Tori pection purposes. ALTER OR ADD TO MCCI I.
L7 (We)agree o save, 'or'
nify and keep harmless the City of Cupmino against
liabilities.judg en "adsand xpenea whichrtayinany Maya me against uiJ City AIR HANDLING UNIT(TO 10,M CFM)
I n core en of amain of this permit. d AIR HANDLING UNIT(OVLR I0.000 CFM)
'ig ere t Fp en o tactor 't Dut EXHAUST HOOD(W/DUC19 PAID
IIA' RDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,IXNI BTU) Date Rettiptp
Will the applicant or future building occupant sere or handle Incautious material HEATING UNIT 100,000 RTU)
as defined by the Cupeniao Municipal Cade.Chapter 9.12,and the,Health and Safety
Code,Section 15531(u)?
❑Yes ❑No VENTILATION FAN(SINGLE RFSID) �
a BOILER-COMP(3HP OR 1 00,000 BTU) ISSUANCE DATE
Wus the ueama drants eats bolined by the Bay
eciMAna Air Quality
ms which emit
Rar<Io.e air conaminants u defined by the Bey Aree Air Quality Management BOILER-COMP(OVER IW,W()BTU) "
ierrin?
❑Yes ❑No NEW RESIDENTIAL ME.CII. SQ.ITp ry. f A I V
T have read the himemous materials requirements tinder Chapter 6.95 of the
Clifford.Health&Safety Code,Sections 25505,25533 and 15534. 1 understand that APR 25 199
if the bailing due,no,currently Imse a mount,that it is my ouponmb;lity to notify the
occupant of the requirements which must be met prior to issue..,of a Coal....of
Occupancy. Cii1 'Jr s
Owner lir amhorized agent Dam ISSUED BY:
OFFICE
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