26072 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOit ILDI .-F.LF. 'RICAL PERMIT NO. c 7
BUILDING DIVISION APPLICATION/PERMI'P PLUMBING-MECHANICAL ZOO 1 Z
BUILDING PROJECT IBPNTIFICA'1']ON
BUILDING ADDRESS: SANITARY NO. APPIICA'IIONSUBMITALDATF.
7 Al �� UNITII LOT# `IQ
OW S f::� PHONE: CONTRACTOR'S NAME: LIC NO,
N(C CONTROLp
RC I]I ENGINIIER: LIC NO: Af FIXS ❑
102-3e HLAFC'U
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
PERMIT ISSUANCE BLDG ELECT PLUMECH
M
E] ❑ ❑
LICOSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DFSCRI
I hereby affirm thus l am licensed under provisionsofChaptar9(commencing with
yz
�00 Section 7000)of Division 3 of the Business and Professions Code,and my license is in PANELS
C U fall far.end effect - /
(Q,Z4l License la Lic.NW-6197 UP T0200AMPS
N[.7vas Date�Contmc ��/y 201-IfNp AMPS
ZO.n ARCHITECTS DB IAItAT'ION OVER I000AMP5 SQ.Ff.MOOR AREA SISQ.f4.
Oz—a I understand my plans shall be,used M public records.
F4 ryn SIGNS ELECTRICAL
seJC Licensed Pmfexsionul
�J OWNER-exempt 3R DECLARATION SPECIAL CIRCUIT/MISC.
xd OaU I hereby affinton.(Se that I am exempt from the Cormarchn's License law for the
413 a y following reason.(Section]031.5,Business end Prmfeesimna Code:Any city or county TEMP.METER OR POLE INST.
bwS oI which requires a Tensor to construct,alter,improve,demolish,or repair any smc6 n, _
W}2 prior toils issuantt.also requimthe epplicanrtrr such pertnitmfileasigned stammer, 1' IP
pE that be is licensed pursuant the provisions of the Conoacmfs License law(Chepmr SWIMMIN 'PoO ELE IO-
4 0 9(commencing with Section 70(Oj of Division 7of the Businessland Professions Cale) r ,s' _ 0 \ - VALUATION
It
4❑y or that he is exempt herefrom and the basis for the alleged exemption.Any violation of
QSmion]031.5 by any applicant for a permit subjttm the applicanu.a civil penalty of L Sr-S TCH - I BRAS—
onot mom than five hundmd dnllma($500) utsbe
❑ 1,atownemOhe progeny,mmymmployeesw,ith wages us theirsolecompensatian. Aq`LRE5H` Efi SQ.I'f. STORIES TYPECONSTRUC[ON
a3= wiltdo the work,and thexwctum isnal alendedoroffemd fortale(See.71X4.Busirfw_
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon.And who does such work himself or through his
own employees,prov ided that such improvements sere not intended or offered for sale.IL OCC.GROUP RES.UNITS
howeverohe building orimprovemern is sold within oneyearofcomple ion,,heow srr- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
ElI,asowneroflheproperry,amexclusivelywnoactingwithlicens cmm ctomto QTY. PLUMBING PERMIT FEE FLOOD zoNC nPN
onswc[the Project(Sec.7044,Business and Professions Cnai The Comment". PERMIT ISSUANCE �
License Law does not apply man owner of pmpery w ho bui Ida or improves thereon,And
who contracts for such pmjects with aconvacmr(s)licensed pursuant to the Comfucmr's
License Law. ALTER-DRAIN&VENT-WATE ) FEE SUMMARY
T ❑ I am excmp[under Sec. ,H&P C for this myon 10
BACK PLOW PROTECT.DEVICE: SANITARY Y N_
9
Owner Dae DRAINS-FLOORROOFAREAGONDRF.CP.119'N
. , . .
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
'❑ Ihcrtby affim,[hntlhave uccdificam mf canunu0 self-imam,ornttnificme of FIXTURES-PCR TRAP RECEIPT#
Workers Compensation Insurance or a certified copy,hereof(See.3800,Lob C.)which PARK TLE Y N
covers all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTIRECEIPT N
Policy N .IT BUILDING DIVISION FEES
Company GAS-P.A.SYSTEM-OVER 4 HDO PLANCHECK FEE.
❑ Certified copy is hereby famished.
Certified copy is filed within city inapec,ian division. GREASRIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE.TRAP SOILS FEE
COMPFASATION INSURANCE
(This serionneednm becom AAAA)ifthe payout is barium hurirmddolhrs(SIM) SEWER-SAN)TARY-STORM EA.200P1'. ENERGY FEE
ideas.)
I ccoify,hat lnthecerfommice.f the work for which this permit is issued,l shall WATER HEATER W/VENT/P.LECTR
not employ Any person in Any manner ro As to become subject to Nc Workers PAID
Compensation Laws of Califomta. Dae WATERSYSTEM/DIEATING Data Raxiptp
Applicant
z O NOTICE TO APPLICANT:FL after making this Certificate of Exemption,
Zr. gyouu mull NEW RESIDENTIAL I'LMB. SQ.IeC 'TOTAL:
C4 become withco subject such pro Compensation prmiaiomof,heLabor yoked.umust
�. � forthwith comply with such provisions or permituMllMdomed revoked. BUILDING FEE
Z CONSTRUCTION LENDING AGENCY SEISMIC FEC
I hereby affirm thatthem is a construction lending agency for the Performance of T ELF.CIRIC ILC
U O the work for which this pmmlit is issued(Sec.3097,Civ.C.)
D. P Lender's Name PLUMBING PEE
lander.Address QTY. MECHANICAL PERMIT PER U I cenify that I have read this Application And state[bat the above infom ation is
aconst. l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
V) building construction,and hereby authorise representatives of this city turner upon the
U 7 abovpropertyentioned property far inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
r-1 (We)agree to aave,indemnify and keep harmless the City of Cupertino against
liabft1lms,judgments ons proves which may inany way accueag.in Isaid City AIR HANDLING UNIT(TO 10,000CFM)
in con cna ting of Chia S�_/_? AIR HANDLING UNIT(OVER 10,000 CFM)
qt t;o-Aa-
Si frallmlWirApplicl Galmi Dam EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEA TING UNIT(M IM.000 BTU) Date Receip,#
Will the applicant or future building occupant store or handle hazardous material HEATING UNI'1'(OVER 100,000 pT11)
de Bocci by[he Cupedino Municipal Code,Chapter 9.12,And the Health And Safety
stet Section 25532(a)7
❑Yes 11 No VENTILATION PAN(SINGLE RESID)
Will thea lican[orfmumbuildin BOILER-COME 011P OR 100,0X0 BTU) ISSUANCE DATE
pp goccupan[uucquipmem ordevicea whichemit
hnzardou.Air comarman[s As defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
D'svid7
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.IT.
1 have read the hexsolous materials requirements under Chapter 695 of the
Calif colu Health&Safety Code,Sec,iora 25505,25533 and 25534.1 understand Nut
if the building does not currently have o¢nam,tial it is my responsibility to notify the
occupant of the requirements which must be me[prior to issuance of a Certificate of
Occupancy.
Owner or authorised agent Dam TOTAL: ISSUED BY: < ' 199
OFFICE t bU CJIIr I