26884 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 'HILDINF-ELL '1 RI A, PERMIT NO.
uuu,ulNf:nlvlBfoN APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING.PROJECT IDFE\1'IF'ICATION 26884
B /G ADDRESS: �(� ��a�d�� (� SANITARY NO. AP/PPLLIIJ\CA'FIOrNSSUBMMII�•TTALDATIi
76,qFO � kyoo Ai �T � UNI1 p LOT# rig gig
OW tRS NAMF,; `� PHONE: NIR 'S NAM" LIEN _ O ll NJ 1,
/1 VN,\f,/LICK VR!Ge N/C COMI'ROLq
RCHITE /ENGINEI3R: LIC NO: ADDRESS
�SB0 ;J / -_' `T ❑
•CONTACT: PHONE: Q'I'Y. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BL 1?LGCT PLUMB MECII
PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
py. I herebyaffiom that l am licensed underpmvisionsofC Vtcr9(commencingwith LOB DFSCRIITION
FOF
Section'/000)of Division 3of the Business anJ l4ofessions Cade,emi my licenu is in PANELS C � Y
U full force and effect.
0.0 ZD UP T0200AMPS
¢F/W erase Clae Lia#
Vi¢6 Dae Contra' 201-10N)AMPS
Fy% nRCHITE/SQ.FT
1iCl .
ZOvr IunderxtunJ my plans ehvll he used vpublic records. OVER I(1WAMPS
OZ—O _
Fon l—w SIGNS ELECTRICAL D ! N
¢ 5_J hI[ensed Professional .; 0 r
syn,'¢ OWNER-BUILDER Df:C1ARATION SPECIAL CIRCUIT/MISE. p p
W U-V 1 hereby affirm that 1 am exempt from the ContramoA License Law for the
X3, y following mashereby
n.of rte th t Ism .Businemit from
and Professions esCode: cense Laver county TEMP.METER OR POLE INST. r L
which requires a permit to convect,alter,improve,demolish, a repair any stmewre
Cadshl its issmmce,also requires the applicant fnrauch no file uai dmarement POWER DEVICES
prior 4mr PP Penni gne
K that he is licensed,msuantm the powWainaofthe Conhows,ex License l,aw(Chaprer
W—p O SWIMMING POOL.ELECTRIC
0.0.0 9(mmmencing with Section]Oo0)of Divisimr3uf Ne Business and professions Cade) V
X
_,, or Nal he is exempnherefmm and the basis for the alleged exemption.Any violimim of
F-ZQ Section 7031.5 by any applicant for a Permit subjects rare applicanno n civil permltyof OUTLETS-SWITCHFS-
FIXTURES
=p tmore than five hundred dollars(ES W). NF,WRESIDENTIALELEC1Z _SQ.FT. STORIES TYPECONSTROCI'ION
K—pa n❑mom
uao rive 0ndred dllarm$50d). yees with wagcsasthcireolecomPemauon,
Pmf—i'ork,andthcmruContranotimm�ded er Law
no, (Sa.to ith war,of
and I'mfcssimss Cttde:The Comramor'n Lianxc Luw docs no,apply m un owner of
progeny who builds or improves rheaon.and whodoes such work himselforthrough his own
employees,provided that.msim
chimpvecrore s anot intended moffered for sale.If. DEC.CROUP HES.UNITS
however,the building or improvement is sold within one yearofcomplerion,theowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale)' PLUMBING PERMIT FEE
[11,asowQTY.
nsner ofthe progeny.am exclusively connecting with licensed coacmrs to I100D ZONE APN
Lconstruct the project(Sea.7044,Business and Professions Code:) Do,Contractor's
iverse Lawdoesnat apply to an owncrofpropcny who builds or improvesdamon,and PERMIT ISSUANCE
who contracts for such projects with a eontraaor(s)licensed pursuant untie Contactors
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt under Sec. .B&P C for this mason OUTSIDE:FEES
BACK FLOW PROTECT.DEVICE
SANITARY V—N
—
Owner Date DRAINS-FLOOR,ROOF'.AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX 'YN
❑ I hereby nationthat i have a cenilicamofcoment to self-insum,ora certificate of IIXTURFS-I'fiR'1'RAP RECEIPT#
WarkmG
s' rmpcnvndonlreuraneeoraurtifcdmpythereof(See.38(X),Inb CJwhiah PARK FEE V N
overs all employee's under this Putnam. GAS_EA SYS'DiM-1 INC.4 OUThEI S RECEI VI'#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division, GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERT IFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thisscdionneed not he cnmplcted ifthe Acranii is fm one hundreddollars(81(111) SEWER-SANITARY-STORM EA.2001cf. ENERGY FEE
ar less.)
I certify that in the performance of the work for which thispermil is issued,l shall WATER HEATER WNENT/ELECTR
not employ any person in any manner an as m become subject to the Workers' PAID
Compensation Lawsof Califomia. Data I WATER SYSTCM/BFATTNG Dme aeipr#
O 2 Applicant
NOTICE TO APPLICANT:If.ager making this Cati6cam of Exemption.you should NEW RESIDENTIAL PLMIL SQ.FT, T AL:
1'Zi (q Jerome subject,,,he Workers Compensation provision m be Ladn Code,ynu must
C� ; fnnhwirh enmity with such prooman,or this permit shall be deemed revoked. BUILDING PE'
G Q CONSTRUCTION LENDING AGENCY SEISMIC EF ,
I hereby amffirram them is a construction lending agency for the pvrf.we of
V O TOTAL: ELE TE
the work for which this .it is issued(Sec.3097.Co.C.)
Lender's Name
u' F LenderPLUs neareaa QTY. MECHANICAL PERMIT FEE '
U I certify that I have read this application and state that the above information is MECHANICAL FE
>- correct.lugreeurtnmply with all city and county ordinances and stare laws belatingm PERMIT ISSUANCE
building construction,and hereby authorize representatives ofrhiscity to enter upon the CONSTRUCTIO TAX
U Z uMwe-memioned progeny for inspection Pmpiiwes. ALTER OR ADD TO MECIL
(We)agree to save,indemnify and kap harmless the City of Cupertino against
I Is.I.Iies,jud mcn1,cost andexpenscswhichmayinanv ayaccmcagainstsaid City AIR HANDLING UNIT(TO 10,IXIO CFM)
in c fthc gaming of Nis t.
�i ro AIR HANDLING UNIT(OVER 10,fM)O CFM)
Sd,isoffiryef Applicant/Contactor Data EXHAUST HOOD(W/DUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING ON]'1'('1'O IM.WO BTU) Date Rece,d#
Will the applicant or future building occuWnt store or handle humorous material HEATING UNIT(OVER 1111 BTU)
IY)'TAL:
as defined by the Cupeninn Municipal Code,Chapter 9.12,and the Health and Safety '
Code,Section 23532Wy! VENTILATION FAN(SINGLE RESIDE
❑Ycs ❑No
ISSUANCE DAIL
Will the applicant or future buildingoccupantuseequipment ordevices which emir BOILER-COMP(3HPOR 100.000131U)
hmardous air contamirim s.defined by Ibc Bay Area Air Qualuy Management BOILER-COMP(OVER 100,00 BTU)
• Distinct?
❑Ycs ❑No NEW RESIDENTIAL MECH.—SQ.FT.
1 have mad the hastnlous materials requirements under Chapter 6.95 of the
California Health&Safety Cade,Sections 25505,25533 and 25534.I undersand that
If the building does not currently have a lenanh that it is my responsibility to notify the � 1 n ���
ecapart of the requireinent.s which must he met prior m issuance of a Cerlificum of HUG a A
Occupancy. 7
Cray Uri ,
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE