26315 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOOH pion."I"C' PERMI"1'NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 26315
BUILDING DIVISION BUILDING PROJC(,9'IDENTIFICATION
BUILDINCk,ADDRFSS: �,/f.'/ SANITARY NO. APPLICATIONSS��UBMMITTIAL DA'1'1
• O Q //{/ UNITN LOT#
OWNERSNAMT:: PHONE: CONT ACTOR'S NAhIJy..n LIC NO:
2-'57-024Z-0 \O•,Ysi�/1F/—_ NIC CONTROL#
• ARCHHI. GINEER: LIC NO: ADDRESS:
CONTACT PHONE. 4 5rI 'BUILDING PERMIJ'INFO
QT�,I V1 BUILDING FEC.'
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE 0 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
CIZZ I hereby affimnhet l am licensed underinevisions ofChapta 9(commencing withTOB DESCRIPTION
u, 00 Sec'Imn 7"o of Division 3 of the Business and Profession,Cod,and my license es in PANELS
y W�. full force lass-flea.
License Clad I.IC.# UP T02011AMP5
m?y D'ac Contract., 201-100JAMP5 SQ.FT.Iy.00R ARCA 5/SQ.FT.
'ONZ ARCHITECTS DECLARATION OVER 1000 AMPS
O Z^G I understand my plans shot[be used as public recmda.
SIGNS ELECTRICAL
qY ,4 LiccnscAProfcssionel I
EE 0� u our lam-BUILD CRD ECLARATION SPECIAL CIRCUff/MISC: pp pp
WOp U I hereby affirm that 1 am exempt from the Cooksm,Cs License i y i for the II —
W 3 a h following risen.(Section 7031.5,Business and Professions Code:Any eery or county 'TEMP.METER OR POLE INST. !�(
i 7 a
m J
which requires a permit to cmnaWCL alms improve,demolish,or lapse,tory shemure s U
YS
poor its issuance,also requires the applicant for such pmoutto file a signed sutement POWER DEVICES
Q tient he is licensed pursuant to th......isions of the Competitor's License Law(Chapter
ixc� 9(commencing with Section7")of Division 3 ofthe Business and Profusions Code) SWIMMING POOL ELECTRIC VALU_TION
nn hat he is exam nhacfomandtbc basis fmnhealle dascr ton.An 1 t f DA
�_'s,n p ge pi ylPnityo OUTLETS-SWITCHES-FIXTUR
FZG nee' nadam fiyannaload cantfora...snit subjects the�pplicantmacivilpenalty of --
orethan five hundred dollars(5500).
E e'ti❑ m NEW RESIDENTIALELECIR _SQ.FT. STORIES TYPE CONSTRUCTION
K ..�ner.f0epropeny.ormycmployeeswithwagcsastheirsolecompensation,
a3Lo ill do the work.and the swcture is not intendWorolfemrl forule(Sm.7044.Business
miss Professions Code:The Contmmors License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work hinandf or through his
employees pmviAed that such improvemenpiarc not intrnd4dmoffertd(orsale.IL OCC CROUP NIS.UNITS
however,the building(it improvement is sold within one year ofroouptetion.the owner- - TOTAL:
builder will Income burden of proving tum he did Trot builder improve for purposeof
mm.).
❑ I,as owncroRhe property.emcmlusively convening weed liceved<ontmcmmo QTY' PLUMBING PERMIT FEE FLOOD ZONE AI'N
instruct the project(Sec.7044,Business and Professions Code:)The Contractor's
Lic-nsc Lew Joesnmt.pply u,anownerofpropcdy whmbuilJs orimprovcs Nercon,and PERMI'FISSUANCF.
whocomarts forsuchpmjects with acoammun0)Iit,,madpursuant to the Coddmters ALTER-DRAIN&VPN.WATER(EA) FEE SUMMARY
Liceraw,Law.
❑nl nm eumpt under Sec. B&P C for this reasonOUTSIDE Flil:.
BACK FLOW PROTECT.D13VICE
SANITARY Y N
Owner —Date— DRAINS-FLOOR,BOOP.AREA,COND. RECEIPT#
o. vs, WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Thereby affirm thud have oticrtificatc of anrvem mulf-insure,oracenifeamnf FIXTES
UR -PER TRAP RECEIPfp
Wmkers'Compenutiun lmurerve oracenifiW copy tbercoflSa.3800,Isb C.)which PARK Fill! Y N
m all employK,uader this permit GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT N
Policy# BUILDING DIVISION F'°S
Company GAS-FA.SYSTEM-OVER 4(EA,) PLANCHECK ITS
❑ Certified copy is hereby furnished.
❑ CedifiedeWy is filed with the city inspection division. GREASFJINDUSTRL WASTE INTERCFOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section most not be completed ifthe permit is formal,hundred dollas(SHW) SEWER-SANITARY-ST ORM FA.2WIcI'. ENERGY FEE
or led.)
I certify that in me performance of the work for whichdd, .it,,issued.I shat[ WATER HEATER W/VENTE-LECTR
not employ any person in any random m as to Famous,subject to the Workers - PAID
ZCompendb.n Lawsof Celifm,ia. Data WATER SYSTEM/TREATING Data Receipt#
Applicant
ZO NOTICE,TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
^ haomexubjcct to the Worker's Compensation provisions of the labor Code,you must
� > forthwith comply with such Provisions or this permit shall be,deemed rtE
vmked. BUILDING FE
C Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
EE
hereby affirm that there is a construction lending agency for the performance of
U O the work for which this permit is issued(Sm.3097,Civ.C.) TOTAL: ELECTRIC ME
II--+-� Leader's Name
u" t-' Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING IEE.
U I certify that I have read this application and spite that due above information is MECHANICAL FEE 0. correct. I agree m comply with all city and county ordinances and state laws relating m PERMIT ISSUANCE
f-' building cormacton,and hereby umhoirarcpresenmtives ofthis city toentn upon the CONSTRUCT ION TAX
U 7-s abovcmemioded property for inspection purposes. ALTER OR ADD TO MECIL
(We)..gram save,indemnify and keep ha,m[ess the City of Cupertino against
Iia"' miss expam swhm y in any waymmuea vast said Ciry AIR HANDLING UNI'I(0 IQOOU CFM)
in tie of the grammit n'
AIR HANDLING UNIT(OVER I 0.II(1)CIM)
Sigrmmre.r pink. odor • Uate EXIIAUSTHOOI OVACUCD PAID
IAZARDOUS MATERI .S DISCLOSURE HEATING UNIT(10 IIXk000 BTU) Date Receipt#
Will the applicant or future buildingo ..pant store or handle hev:vdous material HEATING UNIT(OVFR LW.gp OTU) TOTAL:
as defined by the Cupertino Municipal C e,Chapter 9.[2,and the Health and Safety
Code,Section 255320)7 VENTILATION FAN(SINGLE RI
SID)
ED Yes 13No
C ATE
Will the applicant or future building occupant use equipment or devices which emit BOILER-COMP(3111'OR 100.000 BTU)
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER Ifq,OfN)BTLI
srsmc pp
t ❑Yes 13 No NEW RESIDENTIAL MECII. SQ.FT. P M D
I have read the hazarded,materiets reyuiremems under Chapter 6.95 of the APR Californiahealth&Safety Cmlc,Sections 25505,25533 add 25534. 1 understand that /� 27
ifthe building does not currently have a tenant.that it is my responsibility to notify the /s
cupant of the requirements which must Fc met prim to issuance of a Certificate of C//Y N -#'
a:-dpantiyy. Vr .
Owner or authun.d agent Data TOTAL: ISSUED HY: Yf
OFFICE