26298 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 1 DI .-F,LMARICAL PERMITNO.
APPLICATION/PERMIT PLUMBINGEMECHANICAL
^6^9 8
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION � L L
BUILDING ADDRESS: /^� ,(� ,/J SANITARY NO. APPLI IVRONS`UBMITTALDATE
177/ 7 X?//V 16>0� A5 . UNIT# LOT If
a ERS N/svffi p PHONE: CONTRACTOR'S NAME: LIC NO:
r. ,T,,✓1/1 ,/J I ir' I/C O S" S`F r N/C CONTROL#
ARCHITECT/HNCINEF;R: LIC NO: ADDRESS: �// �� S , ❑
6'1
CONTACT: P�opp11E: BUILDING PERMIT INFO
y. t —goQQTY. ELECTRIC PERMIT FEE
/�
c-�II ELECT PLUMB MECH
CAs,J LD �J — 13od PERMIT ISSUANCE 3Z pO ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
Z=Z I hereby office,thatl am licensed underpmvisionsof Chapter9(commencing with JOB MSCRIPTION
Vc00 Section Division 3 of the Business and Professions Code,and my license is in PANELS
C fol l fore and effect. /� (y/ /�,.�
<Zµ Lienee 1 Liv.# ie S_ 6e � UP T02W AMPS �` � o V(/�(�—�� �r
vFi4L Dare V{�ContrsD �t�r'fl 201 OVER
IWAMPS
Z O os Z, ARCI IIho homed.,
DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O Z_O understand my plans eM1all be used as public records.
SIGNS ELECT RICAL U
d K,'�j Lioenead Profcvelonul
�WU
OWNER-BUILDER D ECLARATION SPECIAL CIRCUIT/MISC.
W 0 W o I hereby affirm than I am exempt from the Contractor's e:Any
Law for the
W 3 m e following reason.(Section construct,
Rosiness and Professions Code:Any city or county TEMP.METER OR POLE INST.
t'J Oe 2 which requires n issuance,
re c irce,the
alter,improve,demolish,or repair any xwnere
r0 pnon0its icensede,alsoret 1.hthe applicant for such peomm,License
La statement POWER DEVICES
4y q0 that he is licensed pumuvmrothe provisions of nhe Commcmr's License Law(Chapter
0.0' 9(commenexisain therefrom and
Division 3ohhe Business and Professions Cod e) SWIMMING POOL ELECTRIC Vgy,UATl0D11
tu..m Sechat tion 7031.5 by anyapplicant
f nhe basisfor
sujealleged exemption.Aivil Penalty el OUTLETS-SWITCHES-FIXTURES (� /fU rJ(/
$-ellen In 7031.5byhundred
dollforapemiin subjcas the applicanimacivil penalty 0f OO ( (/
tit memLtavvn fivevftleep pelt', rs(550o). NEW RESIDENTIALELECTR —SQ.Fi.
¢� o n❑ Lasewrk,anheestructy,ormotimeadvid wifferedacadei(Sec.704,Businemi,ss DRIES TYPECONSTRUCTION
y �e will dothework,Codle: he Contture lsnotinteneese Law doe, f.,Sec.to aBusiness
and Professions CW e:The ves Contractor License Low such
or apply to an owner of
properly whnbuiWsorimpmves thereon,andwhuJcessuch wnhhimselforthruugh his 1
employees,prnvidea thetsuch impmvemems arenmimendedorofferctlf0raele.If, -s3sG0 ES.UNITS
how ever,the building or improvement is sold within one year ofcorepletion,the owner- TOTAL: m s
builder wd l have the burden of proving that he did notbild or improve for purpose f
sale.).
❑ Ir am exclusivelycontraefing with ce nhCoedct t QTY,' y , " NG PERMIT t -
A s
APN
We) uaoonseue, he project(Sex.7044 Business d Profession,Caenra
License Law doesnot apply loan ownerafpmpeny whobuildsortmprovei theronand PERMITISSUANCE DATE
who contracts forsuchprojects with acontractar(s)licensed pursuant to the Contractors ALTER-DRAIN&NEMC-WATBR
License Law. (I FEE SUMMARY
❑ 1 am exempt under Sec. ,B as P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDH FLES
SANITARY - Y N
Owner Dam DRAINS-FLOOR,BOOP,AREA,COND. - RECEIVT#
W MAN COMPENSATION DECLARATION SCH(IOLTAX YN
❑Workers
C. of thatlhave ecenipcate ofconsenuo self-insure,oracenipcate of 171XTURES-PER TRAP RECEIPT#
Wodom'Co redim Insurance ern certified copy thereof(See3800,Lab CJ which PARK FEE Y N
covers oil Ployee's under this etmiL RECEIPT#
PulicyIf — I GAS-EA.SYSTEM-1 INC.4 OUTLETS
BUILDING DIVISION FEES
Comp y GAS-EA.SYSTEM-OVER 4(EA) EN
CHF.CK FEE
❑ coifed copy is hereby famished. 4
Certified copy is Bled with the city inspection division. GREASNINDUSI'RL WASTE INTERCEPTORING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP
COMPENSATION INSURANCE FER
(This section need not be completed ifthe permit is forone hundred dollars(SIM) SEWER-SANITARY-STORM EA,200FT. GY FEE
or leas)
I certify that in the performance ofthe work for which this Permit is ihsued,Isha11 WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to become subject m the Worketa'
Compensation Lnwsof Califnmia. Date _ WATER SYSTEM(I'REATINGDate ReceiptN
Q O
Applicant
Z NOTICE.TO APPLICANT:If.aper making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL: 3O
becomesubjecuotheWorker's Compensation provisions of the LaborCWe,you must t
� ; forthwith c0mplywith such provisions or this permit shall be deemed revoked. INGFEE
W z CONSTRUCTION LENDING AGENCY ICFEE t�
^a 1 hereby aftirrn thuuhere is a oonanmetlon lending ngenay for rho per[omwne of IOTARIC FEE 9 co
U O thewookforwhichthia,.itisissued(Seo.309],Civ.CJ d
Lenders Name _ +x
Lertaera naareaa QTY. , MECIIANICAC PERMIT 'o-t BING FEE
LU co 1 colify that I have read this application and snare that the above information is -' ANICAL FEE
L1s tract. l agree m comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
building construction,and hereby autlmrire representatives of this city teenrer upon the TRUCTION TAX
U ,Z above-memioned property for inspection purposes. ALTER OR ADD TO MECH.
(W0)agree to save,indemnify and keep heartless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10/MIO CFM)
in corse - renting of Nis pe
' AIR HANDLING UNIT(OVER IO,IxNI CFM)
Signntum m Applumm/U marremr EXHAUST HOOD(W/DUCT)
11< GHAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) DaceRaesipultWill the applicant or future building occupant store or handle hazardous materialas deft tied by the Cupertino Municipal CWe,Chapter 9.12,and Ne Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code,SeWm❑m Yet32(a)p No VENTILATION FAN(SINGLE RRSID)
Will thea licanmrfumrebuildin occu tuseo BOILER-COMP(3HP OR IOQ000 BTU)
ISSUANCE DATE
pp g pen equipment Air
ailuro Management
Maundoue air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District9 AID q I�
1:1 ye, No NEW RESIDENTIAL MECH. A '11 SQ.FL P '`�
1 have read the hoz,aQardous materials notimmmems under Chaptef 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534. I understood that ��� (�2�!61994
if the building does not currently have a tenant,than in is my responsibility to notify the - 1
voret a d of he re itenseRa- ich m Mc ma t0 issuance of a hicme of
Ixrreva � s 1
Owner int agent D TOTAL: ISSUEDft'�Y: F
OFFICE