26684 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUILDI G El KUI'RI 'AL PERMIT NO.
APPLICATION/PERMIT PLUMB ING-MRCHANICAL n C O
BUILDING DIVISION BUILDING PROJECT'IDENT'IFICAT'ION L(� v 4I
BUILDING/ACDDRESS(,/{/' /�j/�� / / /' SANITARY NO. APPPPLLIIICCATIOONNNSUH�MMIIITTT LDATE
0/5 ! / • ae LJ I'{Y / - UNIT# LOT# /`� L
0 iRSNAME: PIIONIi: -t• COp'TRACTOR'S NAME: IC NO: NIC COLNTRz
L/� � —4' 4 e .�I a ti
71N
'II:CT/EN NEER: LIC NO: ADDRESSL>G� (L � `� _/^ �y� ❑
FACP: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BIAG ELECT PLUMB MECH
PERMIT ISSUANCE - �/ 0 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDEM'IAI, 10B 9L�SCRIMION
mwz Ihcrebyeffirn thatlarther...droderpmvisiomofairpter9(commencing with, L%✓J
z400 Section 7000)of Division 3 of the Business and Profession Code,and my license is in PANELS ` s�
K� fullfrommdeff5ypI. T/)elG
F,7V,W License Cl... ZZ7 Lie.p 235 UPTO200AMPS roc) s
rn=y Date �� Contractor a' y 201-IOW AMPS S
OO�O� lu�dy� do p ARCHITECTS OPC1iARAT10N OVER 1000 AMPS SQ.ET FLOOR AREA $/SQ.FT.
I✓y�ul ✓//� /(v�/ s SIGNS ELECTRICAL.
6,yf Lieense�t'rofessional
ft y�C OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
0.5d0,U 1 hereby uffirin that 1 am exempt from the Contractor's License Law for the
W 3 wFi following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
�'to which requires n permit to construct,alter,improve,demolish,or repair easy structort
prior to its issuance,ulsm requires theapplicarn formth pemtit to file.signed statement POWER DEVICES
[[vvll ¢O 0tat he is licensed pursuwt to the Provisions of the Contractor's License Law(Chapter
oEt 90commencin9 with Smaon7")of Division Sof the Business and Profession Cade) SWIMMING POOL ELECTRIC / VALUATION
miner he is exempt herefionind the basis far the.11egrAexempamn.Anyviolation of OUTLETS-SWITCI I R9-FIXTURES
GSeer ion 70315 by any applicant for a permit subjects the applicant to a civil penalty of
not marc few five hundred dollars($300). NEWRESIDRNpEALELECIR _SQ.FT. STORIES
..tion, TYPE CONSTRUCTION
❑ I,nsnwnerofthepnpeny.ormyemployceswirhwagaastheireolecompen
a will dome work,and the structure isnot intended oroffered for sale(Sec.70bi Business )
and Professions Cale:The Contractor's License Law does not apply to an owner of /
Napctty whobuildenriarmwes Hereon,andwhadoessuch work Nmulforthmughhis
was empinyecs,pnrvidMthet each improvements arcnotimm�dedmrofferedforsale.If. OCC.GROUP RES.UNITS
however,the building or imprnverm nt is sold within one year of completion,Ne owner- TOTAL:
builder will have the burden of proving that he did not build or improve for pure.of
sale.).
ElLmnwnmroftheprnpeny,am exclusively cnmmctingwi@IicenxJ convactnrem QTY, PLUMBING PERMIT FEF FLOOU'l.ONE APN
consumer the project(Sec.7044,Business and Professions Code:)The Comracions PERMIT ISSUANCE
Licrnu Lewdon nor apply fo an ownerofproperty whobuildsorimpmvesthcmon,end
who contractsforsuch projects with amnarreems)licensed pursuant to the Contractor's ALTER GRAIN -WATT3R(EA)
License Law. FEE SUMMARY
❑ 1 am exempt under Sm. ,B&P C for dds m a BACK FLOW PROTECT.DEVICE OUT SIDE FRES
SANITARY YN
Owner Dam RECEIPTp
WORKMAN COMPENSATION DECLARATION DRAINS-PhOOR,ROOF,AREA. SCHOOLTAX YN
❑ Thereby teff fharlhave oceni0cme of comm malt inmre,orecenificate f FIXTURES-PER TRAP RECEIPTp
Workers Compenmion lmummceora cenifred copy the.](Site 3800,LmCJ whi PARK ME Y N
emter elle 10 cin mdert 's Perron. RECEIPT'#
WWpp GAS-EA.SYSTEM-1 C.40 LEI'S
Policyp 4 /!c✓ -' '� BUILDING DI VISION FEES
Company GAS CA.SO PLANCIIECK TEP.
❑ Ceniful colKy is hereby famished.
❑ Certified copy is filed with the city inspection division. �GftgSyffUML WASTE INTERCEPT OR GRADING FEE
CERTIFICATE OF EXP.MI'd'ION MOM WORKERS' GRB)RTRAP I SOILS FET?
COMPENSATION INSURANCE
(This section need not be completed ifthe permit isforane hundrddollars f5100) SEW SANITARY-STO E .2000 ENERGY FEE
or lise
I certify that in the performance of the work lir which this Permit is issued,lshall WAIF?RHEA iR /vF R
l
not employ any person in any manner so as to become subject m the Workers PAID
Z
Coarse...tinnlswsof Califomia. Date T
WAER SY HATING Dale Receipt It
Applicant
O Z NOTICE TO APPLICANT:If,atter making this Cmat
ifice of Exempti......hoNEW RESIDENTIAL PLMB. SQ.FT.uld TOTAL:
r I/] become subject o the Worker's Compensation pnvisimn offer Labor Cade,you must
�i forthwith comply with such provisions or this permit shall Is,deemed revoked. BUILDING FEE 69'cc
0. (.] CONSTRUCTION LENDING AGENCY 'SEISMIC FEE
- 59
Vz I hereby affirm thatdam is a conswction lending agency for the performance of TOTAL: CLP,LTRIC TEP.
O rhe work for which this permit is issued(Sm.3097,Co.CJ
Lender's Name
0 F Landds Address QTY. MECHANICAL PERMIT F13P PLUMBING FEE
GU1I 1 certify that I have read this applicmion and.slam that the above information is
correct.l agree to comply with all city and cowry ordinances and state laws relating to PERMITISSUANCF. MECHANICAL FEE
F" N building construction.and hereby tonamire repreacnfadvesofrhis city toenterupnn the CONSTRUCTION TAX
U z above-m otioned pmpeny,for inspection purposes. ALTER OR ADD TO MECIi.
G' (We).gree m save,indemnify and keep hvmlcss the City of Cupertino against
Iiabilities,judgments.cmu sndexpenses which may in my way.ccmaagainsbaid City AIR HANDLING UNIT(TO 10,000 CFM)
I.consequence of rhe grmang of Nis permit.
AIR HANDLING UNIT(OVER III,BW CFM)
Signemreof ApplicandConrrmror Dam EXHAUST HOOD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HF.A'I ING UNIT(TO IW,000 BTU) Date RecrN# ry
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100.000 RTU) TOTAL: Gq SU
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Gude,Section 25532(ayt VENTILATION FAN(SINGLE REBID)
❑Yea ❑No
BOILER-COMP(7HP OR R00,000 RTU) ISSUANCE DATE
Will thmrpplicanmrfumrcbuildinguccupant usequipmcm ordevicee which emit
hazardous it comment...tv as defined by the Bay Area Air Quality Management
District? BOILER-COMP LOVER 100.000 BTU) � � 8
C3 Y. ❑No NEW RESIDENTIAL MECIL SQ.FT. qpyy
I have read a
ro hazardous materials requirements under Chapter 6.95 of the 00T 2 7
California Health A Safety Code,Sections 25505,25533 and 23534. 1 undersand tat CC//h
if the building does not currently have a mount.that it is my responsibility to notify the CITY
occupant of the requirements whi h must be met prior to issuance of a Certificate of
Owner or iqrmf pea TOTAL: ISSUED BY:
OFFICE