26511 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO IN"'.EL.ZTIH PERMITNO
BUILDING DIVISION APPLICATION/PERMIT PI.UMnfNG-MECHANICAL -/C C'I ♦I
BI111.UINO PRO :CTIDEMITNICATTf L v J 11
BUILDING ADDRESS: itsV k, LO C. ` Q SANITARY NO. APPLICA9lON SUBMITTALDATE
10 \Oh\tJa l7NIT# �` c \ �—aq,a 9 /
/�-
OW1y€RS NAME 1`o PI A OR'S NAM NO:
� �q � NIC CONTROLM
ARCHITHCF/ENGINEER: ��•//LIC NO: ADD R S:
VWK !:i is u
CONTACT: PHONE: biT: h4". -
S s( ^ QTY.alELECTRIGPERMIT' FEE `^ 6UII DIN(7 PP.RMI'I'INPU
k BLDG ELECT PLUMB MECH
PERMIT ISSUANCE 2 7D^ El 0
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DESCRIPTION
y�z I hereby affirm thin l sm licensed underpmvisionsofampter9(commencing with
00E Section 90x10)of Division 3 of the Business and Profusions Code,and my license is in PANELS q[�
yv� fallLicense,
nse,Chndat@ct. 11 Leo e� Cl r�-• vir/'
Fz W License Class Lic.p 11P T0200AMP5 �L
m 6 y Date Contractor 201-1000 AMPS
Z p,z ARCHITECT'S DECLARATION OVER 1000 AMPS SQ FT.FLOOR AREA $/SQ.lef.
O C_G I understand my plans shall be used m public words.
F y�J SIGNS ELECTRICAL
iQQ��dd ,,...4I Licensed End..imnal
gSyr Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XMXU I hereby affirm that L am exempt from the Contractors License Law for the
fU3tv-m following reason. 91131.5,Business and Professions Code:Any city or county TEMP,METER OR POLE INST.
��Oyg which requires a Permit o construct,alter.improve,demolish,or repair any structure
}7 priori.in i"trence,alsorequirea theupplicaut for such pe.iuo flea signed stnement POWER DEVICES
00 that he is licensed pursuant to the provisions of the Connector's License Law(Chapter
pla� 9(cmnumong with Section 7000)of Division Sof the Business anJ Professions Code) SWIMMING POOL ELECTRIC VALUATION
�WM, or that he is exempt hcmfmm and the busts for the alleged exemption.Any violuionof
EfiSection 9031.5 by any applicant for a Permit subjects the applicant m a civil penalty of OU'ILEfS-SWITCHES-FIXTURES
0 not mom than Eve hundred dollar(5511(1).
❑ I,aaownendmhepmpcny,ormyemPloy<eawithweguavtheirsolecomPrtonI NEW RESIDENTIALELECIR _SQ.EL STORIES TYPECONSTRUCIION
d3� and dnthe wons Code:
The omthe m nt's License Law
rsole(pplytec.7oon Business IV p G/Y ® fS II
and Prey wh ons Grade:The Contractor's License Law does not apply to on owner ofprol11V�1 A.L.\\ N
own em who bui Ids orimproves ch impro mid who
ostrabsuch workuroffredeffor through his
employms,provided thin suchimprovemcrosarenotimendW roffemxd formic.If, � .G P 'S.UNITS
however,the buildingon rT
ar improvement is sold within e yearnfeumpletion,theewner- TOTAL: '"�'
builder will have the burden of proving that he did not build or improve for purpose of
role).
❑ I,asownerofihepmp ay,amexclusivelycontnetingwhhllcens contnctomto QTY S q ' _f PLUMBING PERMIT _ �.FEE p PL O Z NE APN
consumer the project(Sec.7044,Business and Professions Code:)The Convector's PERMIT ISSUANCELicense Law does not army In an ownerofpropermy who builds or improves thurn,and
whocom0acts forsuch projects with a conaacto s)licensed pursuant o the Contractors ALTER-DRAIN&VIiNT-WAER EA
License law. O T ( ) FEE SUMMARY
❑ 1 am exempt unJer Sec ,B&P"Ph
his reason BACK FLOW PROTECT.DEVICE SANITARY O SDE F,s. N
Owner De RC•C[IPI'p
URAINS-FLOOR,ROOF,AREA,CON
VGERMAN COMPENSA ION DECLARA D, SCHOOL TAX Y N
❑ Lomb nthmlhavescertilicumofconsenun Nelf-insum,oracenilictcof RECEIPT'#
Worker'Com FIXTURES-PER TRAP
p<nmtion lmurenceoracenified copy therwf(Sw.38W,Lab C.)which PARK PEE YN
coven all employee's under this permit GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT'#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM OVER 4IEA) PLANCHECK FEE
❑ Certified copy is hereby famished. '
❑ Cenified copy is filed with the city inspection division. ORGSWINDUSTRI,WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS RE
COMPENSATION INSURANCE
(Thi.ssection need not becompleted Brim Permit is foronehundred dollars($100) SEWER-SANITARY-SI'ORM EA.200FT. ENERGY FEE
A
I ceoy thein Nep in any
art, s for becomech this ubject to issu d,labialWorken' WATER HI?n77:R W/VENT/ELECfR
not employ any Person 1i any manner w m to became subject to the Workers' pulp
Z Compensation Laws of Celii'omie. Data WATER SYS'fEM/IRGATING Date Receipt#
ApplicIf.ant z��-t � NcomesTOAPo the Worker's
after Compensation
thisCertificateof of Labor Code,you mind NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
!—I > hecovaidt.eonn the Worker's Compenminis provisiensl be the Labor Cooked. must
III--a�II ; forthwith comply with such provisions orbic Parodi hall beJamr4 invoked. BUILDING FEE
W �] CONSTRUCTION LENDING AGENCY SEISMIC FEE
�J- I hereby affirm that hem is a construction lending agency for the performance of TOTAL: ELECTRIC FEE
L) O the work for which this permit is issuad(Sce.300.Civ.C.) .�
Lender's Name — k-_ 4
Q F Lender's Address Q, �� ",}d s ML'CHANIGAIi PERMIT' FEE, PLUMBING FEC
C) 1 verify that I have read this application and state that the above information is t
combo.I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
�m rA buildingcansvuction.and hereby a dames represenntives of thiscity roenter upon the
U 7 above-mentioned property lot inspection purposes. ALTER OR ADD TO MECI I. CONSTRUCTION TAX
r� (We)agree to save,indemnify and kmp hernleas the City of Cupertino against
liabilities,judgments,cosh and expenses which may in any way acme against said City AIR HANDLING UNIT(TO 10,000 CFM)
in consequence of the gmmia,of thi.+permit.
AIR HANDLING UNIT(OVEN 10,000 CFM)
Signature of ApplioaniXontractor Data EXHAUST HOOD(W/DUCO PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,000 BTU) Dae RuemptN _
Will the applicant or future building computer store or handle haserdoar material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as def ned by the Cupertino Municipal Cade,Chapter 9.12,and the Ihealth and Safety
Code,Section 255320)1
11 Yes ❑No VENTILATION PAN(SINOLI?RPSID)
BOILER-COMP(311F OR 100,"BTU) ISSUANCE DATE
Will tair co icantorfuwrc building occupantuse equipment unlit Management it p
harmdom air contvnismemts m defined by the Bey Arca Air Quality Management BOILER-COMP(OVER 100.000 BTU) P tai '
District?
❑Yen ❑No NI?W RESIDEMI'IAL MECH.—SQ.II'. �
1 have read the hmallous materials requirements under Chapter 6.95 of the7 .19 4
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that
Hthe building does not euren0y have a mnanL talo is my responsibility m notify the
occupant of the requirements which must be met prior to issuance of a Cenifmcam of
occupancy. GIIY tar laurcnun
Owner or as jorrimd agem Date TOTAL: ISSUE
OFFICE