26676 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OPCUPERTINO1i ,HI\.-hLh. 'IRI AL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 26676
BUILDING DIVISION BUILDING PROJECT'IDF.N'rIFiCATION
BUH DD ING/✓AD/D/RREESS: /;/,q
/(/� �/.(///,a ///' �/- SANITARY NO. APPLICATION SUBVIIII'AL DATE
�V /' 04 / (/ "'r 14,OI e- � ♦ UNIT a LOT � �-
OW':aR�VtSIN ME: 22AA.. 11 F C T;A LOR'SNAME /(s -;CO / NIC CO OLp
ARCH] ME fn_
~ LIC ADDRESS:I"!r [F G
ElCONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MIiCH
PERMIT ISSUANCE El ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
I hereh flonthal l am licensed under (Clo mr9 dh LOB DESCRIPTION
OC2 ye pmvisionso p (commemingwi
WOO Section 7")of Division 3 of the Business and Professions Cole,and my licenx is in PANELS � I �� P4 b
W full force and effect 1A\, f`
Ce License Class Lic.N UP T0200AMPS
y6a Date Contractor 201-I"AMPS
H H! ARCHITECTS DECLARATION SQ.PI'.FLOOR ARBA $/5Q.PI'.
'zOvy— lundemmnd my plans shall hused as public records.
OVER IOOOAMPS
OZ O
F rn F; SIGNS ELECTRICAL
Licensed Profnxionel OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
pKOyU I hcrcby affirm that I am exempt from the Contractors License Law for the
[Xil3 avFi following rcuson(Seminn]dJLS,Business and Professions Code:Any City or county TEMP.METER OR PULE INST.
which rect irt.s a permit to construct,alter,improve demolish,or manor any sdmctum
�'�Y5 priono its issuonce,ako requires Neapplicond fmsach pconiuo file a signecistatement POWER DEVICES
.,<O Nat he is licensed pursuant the provisions of the Contmcmra License Law(Chapter SWIMMING POOL ELECTRIC VALUATION
e.ioX 9(commencing with Section 701 of Division 3 of Business and Professions Code)
X0
Section 70.31.5 by anyap'mmanf the permit subjects thedpplica lIn. civil Penalty
of yr/{ D Q�
�7Q Secdion]II3 LS by any applicant fofupcnnit subjects the applicant mecivil penalty of OU'11,E'r5-$WITCI{IS-FIXTURIiS t� L/ I
not mom than five hundred dollars($50b. NEW REMDENTiALELECTR _SQ.FT.
W [II,asawneroflhepropeny,ormyemploymswithwagesmtheirsolecompensadan, ORIES TYPE CONSTRUCTION
6'3 e= will Ju the work,andthesdmcmrtisnolintend<d oraffertdfor sele(Sec.]044.Buaimesa
and Professions Cole:The Comrgwrm,License Law does not apply to an ownef of
prapcny who builds or improves thereon,and who dues such work hiancdfar through his
OCC.GROUP RES.UNITS
empinYees,providedthatouch impmvememsarenot intended mofibmd foesale.If,
however,the huildingor impmvedrrcnr is zu1J within one ymrofcompk6on.the ownef- TOTAL:
builder will have the bufden of proving that he did not build or improve for puryose of
vol QTY. PLUMBING PERMIT' FEE E1.000'l.ONE MIN
❑ [,;is owner ofthe property,am exclusivelycommaTing with licensed common.to
mermen ffic pmjcn(Sec.9(94,Bminess and Professions Core.)The Contramm's
License Lawdoesnm apply to an ownerofpropeny,whobuildsorlmpowes dancing,and PERMIT ISSUANC12
who Contracts fmwchprojeck wiNacontmemr(s)licensed pursuanuodie Coinown,'s ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
Licanxe Law.
❑ I am excmp under Sec. .B&P C for Nis mason - OUTSIDE FEES
BACK FLOW PROTECT.DEVICE SANITARY YN
Owner Dune DRAINS-FLOOR,ROOF.AREA,CON D. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL'1'AX Y N
❑ Iherthy effirmNa lhaveacenificem of ronsenvosdf-insum,oracenifcam of FIXTURES-PER TRAP r RECHIPTN
Workers'Compensation Insurance oracenifial copy Nertof(Sce.3900.Lab C.)whits t
covers all employees under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS � � h � I_ RDIVISION N
Policy DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) �� I�/ P^ b&H K
❑ Certified copy is hereby furnished.
❑ Certified rojty is filed with the city inspection division GREASWINDUSTRL WASTE INTERCEPTOR
CFRTTFICATE OF EXEMPTION FROM WORKERS' GREASETRAP -
COMPENSATION INSURANCE
ClInswelion needrolhccnmpleled if Nepermitls fofonehundfoldollms($10O SEWER-SANITARY-STORM EA.2(N)777 ENERGY ERI?
or Icss)
I cenify that in the performance of Ne work for which this Permit is issued,l shall WATER HEAT ER W/VENT/ELECIR
not employ any person in my moaner u u nme m d do the Werke PAID
Compensation Laws of California. Dam WATER SYSTEMrrMF- TING Dae Receipt#
O Z Applicant
'77F-� O NOTICE T'O APPLICANT:It.after ranking his Cenificamof Exemption,you should NEW RESIDENTIAL PLMEL SQ.PT. TOTAL:
F-' beconmoubjcnm the Worker's Compcnsaian Provisions of the LnMsr Code,you must BUILDING PPE
forthwith comply with such provisions or this permit shall be deemed revoked.
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hcrcby affirm that them is a Continuation lending agency for the performance of
U c) the work for wh ich Nis rm t is issued(Sec.3097.Civ.C.) TOTAL: ELECTRIC FEE
V O p
Lender's Nunt` PLUMBING FBI?
Lender's AJdrcss QTY. MECHANICAL PERMIT FEE
O V 1 cenify Net I have read this application and state that the above information is MECHANICAL FEE
CL. correct.Ingreerocomply with ell city and county oNinances and scam laws relating do PERMIT ISSUANCE
F-' Cn buildiagcomaruction,and hereby authorize representatives ofthis city teenier upon he
abuvcmennimod rt for inspection ALTER OR ADD TO MECH. CONSTRUCTION TAX
V z property pec purposes.
(Wc)ugu Io save,indemnify and keep ham'rthe City of Cupertino against
liahilinies,judgments,oat#ante h'mh may in any way accrue egaina suit City AIN HANDLING UNIT(TO 10.000 CFM)
gaeaceoflh[gmmin f is aQm d.
m corY AIR HANDLING UNIT OVER 10,000 CFM)
1 T EXHAUST HOOD Si nature of APPlicandlCommcmr Dune PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNI' T-C 100,000 BTU) Date Reccipn a
Will the applicant or future building occupant storeor handle harardoumat
s erial
as defined by the Cupertino Municipal Cale.Chapter 9.12,=the Health and Safety IIPATING UNIT(OVER 100.000 BTU) TOTAL:
Code.Section 25532(a)'! VENTILATION 17AN(SINGLE RESID)
❑Yes ❑ No
ISSUANCE.DATE
Will lheappliemlorludumbulldingoccupanuseequipmentordevloeswhiehemit BOILER-COMPLHPOR IW,(NNIBTU)
houII(p�� p,A p�
D
rdous air contaminants as defined by the Bay Area Air Quality Management BOIL 100,00 BTU) 4
District?
❑Yes ❑No NEW RESIDENTIAL.MECH.—SQ.FT.
I have rcad.the hazanloar maerialx requirements ander Chapter 6.95 of the JUL 1 1994
California Ilcuhh&Safety Code.Sections 25505,25533 and 25534.I undcoati d diet
if the building does not currently have a lana.,iia it is my responsibility to notify the
«cupaor of the requirements which must be met prim to issuance of a Certificate or CI I Y Ur v, rett pNU
Occupancy.
Ownonm audi i,rd ngenf Dam TOTAL: ISSUED BY: `a• N' 10 C(�
OFFICE