26892 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO 11 II. 1 .ELKUMICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL ^ ^
BUILDING DIVISION ,7_ZR j't, BUILDING PROJECT IDEMFIFICATION, - [ L
BUILDING ADDRESS: SANITARY NO. 'APPLICATION SUBMITTAL
/3 14:1p/ UNIT# LOq'k {/��
OWNERS# . PHONE,: Or. CONTRACT'OR'S NAME- LIC NO: NUC ` CONTROL#
y
•ARCHITEC IT1JGINEER: LICNO: ADD FS
.t — ❑
CONTACm PHONE:: OP- QTY, ELECTRIC PERIvi1T'I �' MEBUILDING PERMIT INFO
W4;-q i2 BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
pmz I herebyaffiml Nmot l elicensedwdcrprovixiwso(Chapmr9(commmcingwiN TOB DESCRIPTION
POO Section 7")ofDivision 3 of the Business and Rofessions Cade,and my license is in PANELS
K Cf� full force and eIF t.
F2W License Class ¢Q Litt, 3 J/, UPT02MAMPS �t
yQN Date Contractor 201-11100 AMT'S
zOy JJ. ARCHITECTS DECLARATION OVER IgI0AMP5 SQ.Irl',FLOOR AREA 8/SQ.NI',
O Z—O I understand my plans shall he uud as public retards.
F y Igal SIGNS ELECTRICAL
g"E J Licensed Professional
,W< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
RyU I hereby affirm Nat I am exempt from Nw e Commerce.License lafor he
1Ly following Mason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
��� which rcqutr.s a permit to construct,eller.improve,demolish,or repair any structure,
.YE m its issuance,also re theap Iicam forsuch ❑o Bleasi ned statement POWER DEVICES
prior quires pp pmmi g
WO that he is licensed Pursuant to Ne)Provisions of the Cannwmr's License Lew(Chapter
R-e.o� 9that he is exempt Section and the
3ofNe Business ontl.AnyvilaCode) SWIMMING POOL ELECTRIC VALUATION
y_y Sechon7i3151,exempt inaction Ne bmiefonhetsalleged plicari to civil
of OLFG.M-SWITCHES-FIXTURES
zQ Smm ne flu. by any vpplidell. $500).rsubjecsthe eppliconnoecivil penalty of /MIq
A not more Nan five hundmA ny,OT ($5110). FNe
,90
❑ I,esownernfthepropeny,ormyemployecswiN wagamrheirwl.compensation. NEW RFSIDINTIAL ELECfR _SQ.FT. STORIES TYPE CONSTRUCTION
p, will dohhe work,and the structure is not inteadedoroffered forsale(See.7044,Business
and Professions Calc:The Contractors License Law does not apply to an owner of
Property whobuildo mimproves Nereon,and whodoes such work himselfonhrough his OCC.GROUP RES.UNITS
ownemployees,pmvided That suchimprovemenlswe notimended moffered Tarsale.If.
however,Ne building orimprovement iswld withinone yearofwmpletioo,theowner. TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sole.). mm- •.'•
❑ I,as owncrofthe properly,an exclusivelycomacting with limusixicomrwters to r4:: jI'%d ^PLUMBINGPERMFF ' FEE FLOOD ZONE APN
consumer the pmjeet(Sec.7044,Business and Professiom Code:)The Contractor's PERMIT ISSUANCE
License Law dues not apply loon ownendpropedy who builds or Improves thereon,and
whocantmctsforsuch projects with acomructudid licensed pursumno the Contractor's
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMAR
❑ I am exempt under Sec. ,B&P C for Nis reason BACK PLOW PROTECT.DEVICE O
SANIT Y Y N
Owner Date DRAIN$-FLOORROOFAREA, RECEIPTp
. , , .
WORKMAN COMPENSATION DECLARATION SCH LTAX Y N
• ❑ I hereby affirm that l have a cerificare nfmte
nsent to self-insure,or a ecrtificaaf FIXTURES.PER TRAP RECEIPTp
Workers'Compensnlion Insurance or aoenified copy thereof(Sce.3900,Lab C.)which RK FEE Y_N
covers all emylyyeenu c,1 pg t GAS-EA.SYSTEM-I INC.40UTLCTS RECEIPTp
Policy# p[ ZfZ+/ ya2,/����'�—� BUILDING DIVISION F ES
Compon)3( f,pj AAdA an-/� GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK
❑ Cenifred copy is hereby famished.
❑ Ceniftede.py is filed with Ne city inspection division. GREASEBNDUSIRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP soil<FEE,
COMPENSATION INSURANCE
(This sectionnced not hecomp[ered Man permit is for one hundred dollars($101)) SEWER-SANITARY-STORM PA.200Pp. ENERGY FEP
mless.) es
I certify Nal lathe parparmwactfth.work for which this Permit is issued,I shut] WATER HEATER W/VENT/ELECTR
not employ any peroon to any owner so as to become subject as he Workers' N
z Compensation lawaaf Califomie. Date WATER SYSTEM?RFATING Date Ipt#
O Applicant
zz�-I NOTICE TO APPLICANT:IL atter making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
t'+ V) beemnesubjecnn the Workers Compensation provisions of the Labor Code,you must
Hsi ; forthwith comply with such provisions or this Permit shall he deemed revoker. BUILD
0. (] CONSTRUCTION LENDING AGENCY SEISMIC FY
7 z L hereby affirm rhm them is a construction]ending agency for Ne perfomunce of
V O the work for which this permit is issued(Sec.3097.Civ.C.) ELECTRIC FEB
L2.. Lenders Name g 4 . a,
O lenders Address QTY'] ?: MECHANICAL PERMIT PEE] PLUMBING FIiC Nr
I certify that 1 have read this applicmirm and state that the above information Is ° V
LkI careen. PERMIT ISSUANCE MFAHANICAL FEE
�^ y building construction,and hereby ouNoricareproscntmivesofthis city to enter noun berz CONSTRUCTION TAX
U Z above-mentioned properly for impact.purposes. ALTERORADDTOMECH.
(We)aRM,to save.indemnify and kap hwnleas the City of Cupertino al
habtlines,bdgera s.emsandexpenseswhtchmryin wyw .arae. imrwid City AIR HANDLING UNIT(TO 10,000CFM)
naeque
osof he fhhis permit.
AIR HANDLING UNIT(OVER IO,gp CFM)
re of Applicanuilifordracte, Data EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Data Receipt#
Will Ne applicant orfar..building oecupam short or bond[.hvardom maasiel HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,undone health and Safety
Cede,Section23512(n)T
ElYes 11 No VENTILATION FAN(SINGLE RESID)
❑
Will the applicant orfurumbuildinga,upwtusecquipmenmrdevias which emit BOILER-COMP(3HPOR 100,000 BTU)
heamdon,air commoreads as defined by Ile Day Area Air Quality Management•
Diavm7 BOILER-COMP(OVER Il10,IX10 BTU) 661 8 /ddb
❑Yes ❑No NF.W RESIDENTIAL MECH. SQ.FT.
1 have read the ho:ondom mmends r Mamma nem uadef Chapter 6.95 of Ne Q 61
California Health&Safety Cade,ly have.
to 25505,25577 and 25574. I ityderunJ t YY� C J
ifcupant dingdasnalcmris which
e, that prior
is my responsibility to notify the
occupant of the requirancros which must be mm prim m issuance of a cenifica¢of
Occupancy. IUs
Owner or authonud agent Data TOTAL: ISSUED BY: V
OFFICE