26117 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUICITY OF CUPERTINO PLUMBINGPERMIT"°
-MECHANICAL 2 6117
BUILDING DIVISION APPLICATION/PERMIT = n , „ BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITTALDATE
UNIT# LOT#
(� SNAM . PHONE: CT 'S NAME LIC NO:
o, ✓✓✓
F NIC CONTROL#
Aptqf
R HITF.CT/ENGIN R:znP_ LIC NO: D LS r t�
CONTACT: PHONE: 'W a 9^'F99' bG•Y>S nF R t ?:.^)4:(i;m `.
09V (p'Y1 . BL'B 11 PERMIT„ { tf,ax'FEB "'x BUII:'DING PERMIT INFO
��7l T Sk i UAN 4 d' a s I v N' o v a BLQ� Ey�C'[ PL ME
' PERMIT ISSUANCE
LICENSED CON O D N APPLIANCES-RESIDENTIAL
Dyy Iherebyo inn that]am licenaedmnda pmvi ns cfChapler9(commencingwith JOB DESCRIPTION
F100
full forty e�)oUDillo, 3 of the Business and Professicns Code,and my license is in PANELS
<ZW License Class Lie.# �1�rT� UP TO 200
m6L Dam Crmostam MI-POWAMPS
EEyZ ARCHITECT'S DECLARATION SQ.PT.FLOOR AREA $/SQ.IT.
Z'p m— I understand my plans shall he i ed as public records. OVER 1000 AMPS
mt"
r ,
SIGNS ELECTRICAL
6 '� Licensed Professional
g9 y I OWNERTUILDERDECLARA'IION SPECIALCIRCUELMISC. ��
�O U I hereby M.that I nm exempt form the Convacto's Lieene Law for the
W 34t N following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
aJ which requires a permit to consumer,alter,improve,demolish,or repair any sumaure
'y'} prior to its issuance,also requires the applicant for such permit to flea signedsmtemem POWER DEVICES
yq 4 p that he is licensed pursuant to the provisions of the Contractors License Law(Chepmr
dmpP` 9(commencing )o SWIMMING POOL ELECTRIC
( gwith Sermon]000 of of Business and Professions Code) VALUA1TIOaN. r`
W=rn orthat7031.5 by anyapmmnnd t for a basis fonhectsalleged antociviny l
of OUTLETS-SWITCHES-FIXTURES
Y Section e is ex by any applicant fore permit subjects the applicant exemption.a civil penalty of
Anot mom than five hundred dollars(SSW).
NEW RESIDENTIAL ELECTR _S .PT. STORIES I TYPE.CONSTRUCTION
❑ othe wok,andthrrpeny,e is not ployeeswhhwagesasalei(Sec.compensation,
p, will drlhework,nolo:Th Cinarsnm i.License La a al due,otup,],to 4,Buhe,of
ess
and Professions Cole:The Contmmor's License Law Aoes no[apply w an owner of
property wM10 buildsorimproves thereon,end whotlres such workhimselforthroughhis
OCC.GROUP RES.UNITS
employees.provided that suchimprrvements mnorintendodorofferedforaale.If,
however,thebuildinguimprovementishat he idnoneyearofimproveforfieowner-
builderwill have the burden of proving that he did not build onmpmve for purpose of
sola). FY9 n.Rr p . .
❑ arnneproperty, QTY xsx tra PLUMAING PERMTT, --=FEE
Ina ownFLOOD ZONE APN
p p y,amoxelustvely contracting lammed exameto t eFa k$ s#?r ITr:
construct the project(Sec.](004,Business rad Pfofessions Code)'The Contractor's
License Law does notepply manownerofpropeny whobuiltls mimphomitheraceMand PERMITISSUANCE
who amtmets frrsuch projects wiN aconvecmr(s)licenxed pursuanuo the Convadors ALTER-DRAIN&VENT-WATER(EA) - 'FEE SUMMARY( .
Licene Law.
❑ I am exempt under Sea ,B&P C for this reason BACK FLOW PROTECT,DEVICE OUTSIDE FEES
SANITARY Y N
Owner Data °RAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Thereby s[fimmthatl haveacertifieale ofeoneenno self-insure,oraaenificate rf FIXTURES-PER TRAP RECEIPT#
�Workers'Compeneetion Insurance or a codified copy thereof(Sec.3600,Lab C.)which PARK FEE YN
covers all employee's under this permit. h� .�/ GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# rl t0 BUILDINGDIVISION ECEIPT#FEES
2•ny - GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
Certified copy is hereby famished
❑ Certified copy is filed with the city inspection division. GRFASMISDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need notbe completed Bills permit is for one hundred dollars S IW) SEWER-SANITARY-STORM EA.200FT. ENERGYFEE —s'
or less.)
I codify that in the Performance of the work for which this permit is Found,l shall WATER HEATER W/VENT/ELECTR
not employ any Person in any manna so as to become subject to the Workers' PAID
Compensation Lawsof Celifnnia. Date WATER SYSTEM/TREATING Dam Recei #
O Z Applicant
Z NOTICE TO APPLICANT:If,after making this Cenific nd of Exemption,yon should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
Fbecome subject to the Worker's Compensation provisions of the Labor Code,you must
a , forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
Lkl Q CONSTRUCTION LENDING AGENCY SEISMIC
z I hereby infirm that there is a crnsbucmrn lending agency for the performance of T ELF.CfRI E
U O the work for which this perm¢is issued(So.3097Crv.CJ
Lenders Name t P- <:
W F Lmiaera Aadreaa QTY. -.,� ;MEC4IANI-AL:PERMI71 v T t'g aF.EE' - PLOmn"ILE
LU2a I certify that I have read this application and state that to above minimal.I, ` ' -
MEC AL P,E
reel.ingree to comply with all city and warty ordinencesand atom laws mletlogro PERMIT ISSUANCE
building construction,and hereby authmicampresentathosof this city to enter upon the
above-mentioned rtfor inspection purposes. ALTER OR ADDTO MECH. CONSTRUCTI NTAX
U We 1.show,iindemniif c nd keep the Ci f Cu nino against '
( )agree y nn p ry o ga gains
liebilihes,judgments.costs ondexpenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10.000 CFM)
in dome, mntingof pandit.
AIR HANDLING UNIT(OVER 10,000 CPM)
Si ammo Ile vac
Data EXHAUST HOOD(W/DUCT) I
PAID 6-0
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Ilealth and Safety
Cade,Section 25532(a)P VENTILATION PAN(SINGLE RESID)
❑Yes ❑No
ISS ANCE DATE
Will lhoapplicamorfuwrebuilding owupentusaequlpmwmrdevioeswhiohemit BOILER-COME(31{p OR IW,"BTU) pp p
loos air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) r sq
_ evicfl
1 ID
❑Yes ❑No NEW RESIDENTIAL.MECH. SQ.Pf
LlIcalth
haveread the hazadous materiels requirements antler Chapter 6.95 of the 1419gA
alth&Safety Code,Sections 25505,25533 and 25534. (understand That /r .
g does not currently have a tenant,that it is my responsibility to notify theC/he requirements which must be mel prior to issuance of a Certificate ofhmizedagent Data T ISSUED BY:
OFFICE