26082 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HB,.,��hinou frt UAL' PERMITNO,
APPLICATION/PERMIT PLUMBING,-MECHANICAI, 26082
BUILDING DIVISION BUILDING PROJECT'IDENTIFICATION
BUILDING ADDRESS: oo q q ft Z'Cr l SANITARY NO. APPLICATION SUBMITTAL DATE
Ol �• I I l- I UK"" LOTp Q -�
OWNERS NAME:�('1�' � / PHONE:�+ CONTRACTOR'S NAME: ; LICNO: NIC CONTROL JI l� aa0 ,—I . 5,19S <qjxn
•ARCHITECT/ENGINEER: LIC NO. ADDRESS:
Elloo a""` SAN 2
CONTACT: So5 PRONE: - 3� QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
J I/t11
Q
40oQ ITS /,5GY Arm BLDG ELECT' PLUMB MUCH
�I PERMIT ISSUANCE fCb El C1 El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL K�
pyz I hereby affirm that l amlicemeJ underprnvlsinnsof Chap¢r9(cnmmcnem,with -4 14e,
JO/H IDFSCRIPI'ION
aQ00 Section 700B.f Division Sof the Business and Professions Cade,and my liecree is in PANELS ChlhPl�r �SIr
yamF—. full force and effec. pI
<jW Liccnu ClusJJ�Tic.# UPTO2(IOAMP$ rlr�� (,k>
ti?y Dare ]—Cnntructor-Si eS/MS 201-His)AMPS Y
,0yz ARCHITECTS DECLARATION OVER]"AMPS SQ.FT.I7LOOR AREA S/SQ.PI'.
0 z— I undeamm�d my plans shall be axd u public necoNs.
k 04 SIGNS ELECTRICAL
NQy Licer'd Professional
y d'< OWNER-BUILDER DECLARATION SPECIAL CUTDMIS
dxOa V I hereby affirm that 1 am exempt from the Comrmmr's Lianx Lew for the
W3LLy following reason,(Seetion 7031.5,Business and Professions Code:Any city or county
TIME.METELE INST.
ermit m sw
F tojO< which merries a pconct,at req improve,demolish,or repair any sumenne
�tyyjYM primmit issuance.also requires Nc applicant far such permiuo fileasigned statement POWER DEV E'
.25<0 that he is licensed pursuant to the provisions of the Calibration's License law(Chapter
o.pno 9(commencing with Section 9000)of Division 3 of SWIMMINPOOELECTRIC he Business and Professions Cade) VALUATION
X LL ar that he is exempt thertf rom and the basis for the al le dexemption,An 1 t f
p geylPnityO OUTLETS-SWITCI IGS-FIXTURES /'
H Z Q Sermon than by any applicant fora permit subject the applicant a civil penalty of a q Q -OZ1
5 0 not mom thanfive fffie re ay,ormycmdollater ). NEW RESIDFNTIALELECIR _SQ,FT.
❑ I,asowncrof thegmpcny,nrmycmployeeawith wages ustheirsolccompensation. STORIES TYPE CONSTRUCTION
yg_ will do the work,and thesounure is not immradedoralfered forsale(Sec.9144,Business -
and Professions Cade:The Contractor's License Use does not apply to on owner of
property whobuildsorimprovesthere<m,and whodoes such work himaefor#rough his OCC.GROUP RES,UNITS
own improvements employees,provided that such impvemes one notimanor
dedoffered foliate.IL
builder
r.will have
the prim idprovmLsat he
inone ywr or infants
on,for the f 'TOTAL:
builder toil l have the burden of proving that he did not build or improve for purpose of
"1e')' QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ 1,asowner ofthe progeny,=exclusively contracting with licensed commnotxm
Linstruct 0 e project(See 90FL Business and Professions Code.)The Contractor's
icense Lowdoes not apply to an ownerofproperty whobuildsarimproves flamm nd FERMI TISSUANCH
whocontmns for such projects with acantrsnm(s)licensed pursaanumhe Coneracrrs gL'IFR-DRAIN&VENT-WATER(EA) FEESUMMARY
laccase Law.
❑ 1 an exempt under Sec. ,B&P C for this re mon BACK FLOW PROTECT.DEVICEO OUT FIES
SANITARY Y N
Owner Dam DRAINS-ILOOR. FARPAGOND. RECEIP #
WORKMAN COMPENSATION DECLARA'T'ION . , SCI 1001.TAX YN
❑ Thereby ul9rm Nmlheveucertificur nrcaneonua self-insure.nrncuri9catc of FIXTURES-PER TRA RECEIPT#
WorkersCompensation humads,m.certified copy theavd(See.3900,Lob C.)which PARK FEE Y N
covers all employee's undcnhis permit. y IT411K3 _QS GAS-FA.SYSTEM_I W- .40 EfS RECEIPT#
Policy p BUILDING DIVISION FEES
—cT- '
Cmnga^Y—orf" ,a .GAS-EASYSTEM-OV (E "t PLANCHECK FEE
L4 Camped copy is hereby fumished.
❑ Cenified copy is Bled with the city inspection division. ..t%� GREASFA US EINTERCEPI'OR GRADING FEE
CIiR'1'IPICATE 017 COMPEN.ATIONIIIN MOM NSURANCE WORKERS 0 �p � ' GR AIH' �l " SOILS FF.F.
(Thisxctionncednmbecomplacd ifthepermit lsforone handl 11.(S 000) SEWER ANITA S EA.if
0014.1 ENERGY M-C
nr less.) 7 r v
Icerd that in the peffernanecof he week for which this permit ms'ssued,lehall WATER i- TE /HLF.CTR .t
not employ way person In any manner se as ar become sobj el m Walken' a PAID
Compensation Licasof Califomia. Date S IlsTING .' Dam Receipt#
C) z Applicant k —
z NOTICC'TOAPPLICAN'DIf,eBermaking this Cmm9cmcofExet tion.youxhauld NEWRESIDEN IAL PCMB; SQ.F. TOTAL:
E•-' i,, Mrame subject to the Worker's Compensation provisions of the Le Cade,you must
a > fanhwith comply with such provisions or this pemrit shell be deem liked. BUILDING IBE
a (� CONSTRUCTION LENDING AGENCY ...a.N"x'1'"' SEISMIC FEE f
z Ihereby affirm that is a nmsuuction lending agency for the Performance of TOTAL: ELECTRIC FEE
U O the work for which this permit is issued(Sec.3097,Civ.CJ
CT, P Lender's Name PLUMBING FEE
Lend,,,Address QTY. MECHANICAL PERMIT FEE
U I cedify that 1 have read this application and .at that tht above information is MECHANICALFEE
1 correct.l agree m comply with all city and county onirences and state laws reining to PERMIT ISSUANCE
buildingeonaruction,and hereby aothoriu reprtsenwtives of this city mercer upon the CONSTRUCTION TAX
U z above-mentioned property for inspection puWars. ALTERORADDTOMECE.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Iiabilities,judgmen¢.emas adexpenses which may in any wareacerue against said City AIR HANDLING UNIT(TO 10,000 CFM)
in consequence of the granting of this permit.
AIR HANDLING U (OVER 10,000C )
Signature of Anlricant/Conuacmr Date EXHAUST HOOD(W UCI)
HAZARDOUS MATERIALS DISCLOSURE
HEATINGUNIT(TOI , BTU) wane Receipt#
Will the the Cupertino
or future building de,C ant erre or handle haealth a material
as defined by the Cupertino Municipal Cede.Chapter 9.12,and the Health and Safety HEATING ON]'1'(OV- W.IpII BTU) '1'O1'AL:
Code,Section 25532(.)? VENTILATION In IS GLERESID)
❑Yes TN.
ISSUANCE DATE
Will thcappllwrorfntum building«cup tum quipmcntordeviceswhichemit BOILER-COMP(31POR 100,0000TUl
ha[adous air comamimams as defined by the Bay A.Air Quality Management BOILER-COMP(OVER 100,000 BTU)
DisWet? 1:1A B A
Yes IWNo NEW RF,SIDENTIAL MECB. SQ.Fr.
I have mad the hsoulful materials requirements under Chapter 6.95 of the
1 uJUN 30 1995
Culifomiu I Icalth&S.I'dy Cudc,Stations 255115,23573 and 255]4. nderswndat
Gh
if the building does not currently have a¢num,that it is my msponshifiq to notify the
occupant of the mquim rat which must be met prior to issuance of a Certificate of
Occupancy.
I I Y Vr in IIVU
Owner nr uuthoriecd gent Dam TOTAL: ISSUE
OFFICE