26663 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO UMBING-F.LEC'f NIA. PEPU4IT No.
APPLICATION/PERMIT PLUMBING RING.MRCHANIFIC
BUILDING DIVISION Ru11.0PNG PROJECT IDENTIFICATION 26663
BUILDING ADDRESS: �/' SANITARY NO. APPLICATIONSUBMITTTAALLDATE
/Q,Q3 �D Flt UNIT# s LOT \ 2
OWNERS NAME: PI10NE: CONTRACT'OR'S NAME: I.IC NO: NIC CONTROLN
L,9 B u >L - S ma an It1Z 4Pl A5-p
A RCI 11'FECI'/ENGINEER: LIC NO: ADDRESS: _/ ❑
J O .
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE. BUILDING PERMIT INFO
BLDG ELECT PLUMB MIiCH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENIAL C PITON
Q=z I hereby affirm that l an licensed underprovisionsofaripter9(commencing with
P000 Section 7000)of Division 3 of the Business and Profession Cade,and my license is in PANELS
fu 11 Rmrce anJ elle t. _
< Iy License Clash `hie.p UP T0200AMPS
rFxr�y Date/]-yIt Comm 201.1"AMPS �
z F0 ARCHITECT'S DECLARATION OVER 1000 AMPS SQ,FT.FLOOR AREA S/SQ.Fr.
O z—Fp W❑ 1 understand my plans shall he used as public records.
r,'rn SIGNS ELECTRICAL
<y 2
� Licensed Nofessicnal
='44 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
rsx�t'O yU 1 hereby affirm that I am exempt from Ne Convacmrs License Law for the
t+13 a h< following mason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
J which requires a peanut in construct,alter,improve.demolish,or repair any muctute
} ionan
� pr .its issuce.also requires th
eapplicam for such pemutm Nut
easignedscmrnt POWER DEVICES
A 0 Nut he is licensed p.......the provisions of the Convectors License Law(Chapter
O
dT 9(comrmsmg with Saxian 7")or Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
w oe or that he is exempt hemirom and the basis for the alleged exemption.Any violation of OIff1.F.T5-SWITCHES-FIXTURES
4 Section 7031.5 by any applicant for a permit suhjecu the applicant m a civil penalty of
G not mom than rive hundred dollars(S50m.
m ❑ I,mownerofthepropeny,ormyemployeeswithwagesmtheirs.lecompensai.n, NEWRESIDENTIALELECTR _SQ.M. STORIES TYPE CONSTRUCTION
y3� will do the work,andthe structure is not imcndedotmffered formic(Sm.7044.Business
and Profession Code:The Convector's License Lew does not apply to an owner of
pmpeny who builds orimproves thereon.malwhod«ssuchwork binaalfor through his OCC GROUP EA
own employees,provideddrusuch improvemermtsae not intendedoro(fend forede.If.
however.Nebuilding or improvement is sold within ose yearn
.fmanpleti. ,the owner. TOTAL: /
boulder will have the burden of proving that he did rant build ar improve for purpose.f C
sale.).
❑ Lus owner.flhe propeny,emexduxively conuuting with licensed conlncmrsm QTY. PLUMBING PERMIT 1 FLOOD ZONE
construct the project(Sec.7044,Business and Professions Code:)Tbal Contractor's PERMIT ISSUANCE
\
License Law does not apply..an ownyr of properly who builds m imro
pves Hereon,end
who contracts formeliprojects with a wmector(s)licensed pursuant to the Contractors pLTBR-DRAIN&VP.NT-WATER(EA) \J
License Law. FEE SUMMARY
❑ 1 am exempt under Sec. .B&PC for this mason BACK FLOW PROTECT,DEVICE SIDE FEE
SANITARY Y N
Owner Date RECEIPTp
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMP ENSATIONDECLARATION SCHOOL TAX Y N
Workers
Co affirm ontlhrvevicenificmeof consent..sdr-insure M,aid,..)which
FlXTURFS-PF.R TRAP RECEIPfp
Workers'Compensationlnunna orecenified mpY Hereof(Sa.3800.Lab CJ which PARK FEE Y N
coven all emploY� oder Nis perm it. GAS EA.SYSTEM-1 INC.40UTI.EI'S - RECEIPT
Policy# Y�� BUILDING DIVISION FEES
Company :fC';Fe GAS-EA.SYSTFM-OVER 4(EA) PLANCHECK FILE
❑ Ceniried copy is hereby famished.
❑ Ceniriedcopy is riled with the city inspection division. GREASElINDUS'I'RL WASTE INTERCEPT OR GRADING PER
CERTIFICATE Or EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed Brun permit is f.rone hundrsidollare(SIM) SEWER-SANITARY-STORM EA.201FT. ENERGY FEE
or less.)
I cenify that in the perfomance of the work for which this pemdt is issued,l shall WATER HEATER WIVENT/ELECFR
not employ arty person in any manner co a to become subject to the Wm1moi7 PAID
z Compensaiontawsof Califomia. Dae WATER SYSTINITRGTING Dme RecxiplN
Applicant
FOQ NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB, SQ.Ff. TOTAL:
U) hecnmesuhjecna He Workers Cian oration Provision of the Labor Code,you must
a ; forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
W z CONSTRUCTION LENDING AGENCY SEISMIC FTP.
rrR--mm 1 hereby air=that there is a construction lending agency for Ne performance of
V O the work for which this permit is issued(Sm.3097,Civ.C.) TOTAL: ELECTRIC FEE
Lender's Name
U Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING PER
1 certify Nat 1 have mad His application and awe Nat the above moratorium is
;" 0. MECHANICA
comer,I name to comply with all city sal county oNinanas mad sum law,mining to / PERMITISSUANCE L FIiE
Ln building construction,and hereby authrrim mpresenutives ofthis city..enter upon the
U 7 ohov me�j'on ed propmyfnr inTrun purposes. ' ALTERORADDTOMECH. CONSTRUCTION TAX
f=7 e(�?"agme m save,indemnify and keep hennless the City of Cupertino against
liahi li))�:`
gments,costsa xpcnsea which arm, y wayaccmeagvinsl said City AIR HANDLING UNIT(TO 10,000 CFM)
in eof Hegrmgr thia permiwAIR HANDLING UNIT(OVER 10,000 CFM)
ppre muawn /�— Dna EXHAUST HOOD/W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt Is
Willthenppikant or future building acupant more za
or handle humorous ma¢rid HEATING UNIT(OVER IN,"BTU) TOTAL:
es turned by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Cale.Section 25532(a)?
13 Y. VENTILATION PAN(SINGLE RFSID)
bNo
BOILP.R.COMP(3HP OR I W,000 BTU) (ISSUANCE DATE
Will the applicantorfuwre buildingacupnm uueyuipmemmdeviceswhich emit
hazurdon it ,mucommons as dcMcd by the Ray Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
Dlatderr
❑Yea ON. NEW RESIDENTIAL MECH. SQ.PT. NOV 22 1895
I have re the hazardous materia mourrvents under Chapter 6.95 of the s7
Celi(nmI I u h&SarelyCode,Sec' s 505,25533 and 25534. 1 understand that CII Y Ur UUh'EHIIa,,,.
lithe M1in n nmcuvemlyh at antthatitnmy risibility..ratify the
..'an sf a nNuiremenu w h must be met poor s an of a Cenifmcam.f
Or
Own ormthodzalegem Dm TA%_1 ISSUEDBY:
OFFICE