26410 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BIH.UI c-EL-EC RLCAI. PERM]TNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 26410 C /I4 1'I O
BUILDING DIVISION BUII.DING I'ROJRC'1'IDBM'IPICA'IION ' o
BUILDING ADDRESS:�^] � SANITARY NO. APPLUAT/Nk SUBM 'ALDATE
/VQ(`A 3 /-^�7' UNIT# LOT# r] `� R+
OWNERS E: PH NI?: C NTRACI' 'S NAME: I O: NIC C NTROL l
• 4 d
RCHI'I'I?C /FNGINCP / LIC NO: AD RRSS: ❑
CONTACT: PHONE: A33
BUILDING PERMIT INPO 14
CJn✓ —r^ 5- 57AI-7`2/, QTY. ELECTRIC PERMIT FEE
/// (JQ I ELECT PLUMB El
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
O[�pgz IhercM1y affi.vhalamlicenmAunderprovisionsofChaDter9(commencingwith //�J�� ��y�.�N--��Na#g ,''''.
a`JOO_F. Section Than of Dlvldm,3ofthe Bushmss and Professions Cade,and in,Road.is in PANELS ! '�✓ L%U•q/WY 60
Fv„ut Liclenu Ciaceffe Lic.# [ �W
QVU _--� _a�2� UP T0200 AMPS
sFn-6y Did Contra 201-I"AMPS
Z8y4 TIECTS DEC N OVER IWOAMPS SQ.FT.FLOOR AREA E/tiG.FT.
OZ—C IrMerstanin,pImoiuball be needaspublicre rds.
P:y W SIGNS ELECTRICAL
qq Licensed Promadinnel
OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
�x Owu I hereby affirm that 1 am exempt from the Contractors License Law for the
W3V-y following maim.(Section 7031.5,Business and Professions Cale:Any city or county 'lliMP.METER OR POLE INST.
which mgairw a pcmnit to construct,alter,improve,demolish,or repair any structure
N� prior to its issuance,ulsorequioes the a,Nicantfor such Permit o file a signed statement POWER DEVICES
a_M
aO that he is licensed pursuant to the provisions of the Contactors License law(Chapter
Lo ' 9(commencing SWIMMING POOL ELE C
5� ( empthherefrom add
Division 3e alleged
Professions Code) VALUATION
W_rn orthat 7031. h,itoyrcfromznfor
the hasisforijeailegcd exemption. civiny l
of OUT LETS-SWITCH -Fl%'L'I1RE5
4 not.
Section than byuu dred d.11.($3cnnit srbjects the applicannouuivil penahy of
not more then five hundred dollars($300).
C � ❑ I,aenwnero0heprnperty,0rmyemployeeswith wagessstheirs0lecompcmetian, NEW RESIDFNTI .[LECfR _SQ.FT. STOMPS TYP CONSTRUCTION �
y 3.. willdmhework,and the twoure isnot imendedoroffered forsale(S.,7041,Business
and Professions Code:The Contactors License Law does not apply to an owner of
properly whobuildsor improves themorrand whodoes suchwork himself orthrough Itis
own cmployeas,provided that such improvements are notiacnd,d mofleredfmsale.If, OCC,GROUP RES.UNIT
however.the building orimprovement is sold withinone yearofcompletioq the owner. /l—
builderwillhavetheburdenafprovingthathedidnotbuildorimproveforpurposeof TOTAL' (F
e.I.
Cl I,v nwneraftbc prop,ny,amexdusivelycamracting with licensed convacmrs to QTY. PLUMBING PERMIT FEF. FLOOD ZONE AI'N
conmruct the proieol(Sec.7044,Business and Professions Ccule:)The Contractor's
License lawdoesnot apply to an ownerofpropety who builds mimprnves thereon,and PERMIT ISSUANCE
whocontacts fursuch projects with u nmb urmt.)licensed pursuant.the Contactors
License law. ALTER-DRAIN& ENT-WA'IER(G) _ FEESUMMARY
CII am exempt under Sea. ,B&PC for this reason HACK PLOW PROT:CT.JNIdr, DOISIDE FEES
1. i'"t S I Y N
Owner Date EECEIITp
WORKMAN COMPENSATION UI?CLARATION DRAINS-FLOOR,ROOF RE 'CONED 1� -tT I— TA% Y N
• a❑ I hereby affirm that l have a certificate ofconsentto self-insum.or a certificate of ...v avREC..IVI'N
FIXTURES-PERT AP _P It F8B
Workcn Cumpcnsmion Imumnce arsecertified copy thereof(Sec.38W,Lab CJ which p'e' Y N
era nil employ Ago - oEn CAS-Eh gYS'I'1? -I INCA yyryfd'� RDIVISI N
Policy !l BUILDING DIVISION PEES
CompanyGAS-P.A.SYSTI?MOVER 4IFA) PLANC ' EE
ElCertified cap,i mm fuaished.
XCetifial copy is filed with Ne city inspection division. GREASEANDUSTRL WASTE.INTERC OR GRADING FEE
IX
CER,IIICATE OF EX17MMON FROM WORKERS' GRHASETRAP SOILS FEE
COMPENSATION INSURANCE -
(This section need not be completed ifthe permit is foram,hundred dollars(SIW) SEWER-SANITARY-STORM .2WIT. ENERGY FEE
or less.)
I card fy that in the perform f of the work for which thisl1�� "t is issued,l shall WATERHEATERW/VENT _ECTR
m employ any person in an n anter sn as}yn(aer# WR�the Workers' PAID
Compensation Laws nfC l' me J+�/LLff�� LJ L WATER SYSTHMITRW NG Date RccciptN
Z APPlicam
Z 2 NOTICE TO LALMB.
APPLICA ,ante eking this Cerificem of Exemption,you should NEW RESIDENI' SQ.IT. TOTAL:
Q, become subject the Worl 's Ca motion provisions ofthe Labor Code,you muse
a. forth,air comply withxuch provcomns or this pimnitshill be deemed revoked. BUILDING FEF.
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1 hereby affirm that hem is a commuction lending agency for Ne performance of
V the work for which his penult is issued(Seo.3097,Civ.C.) TOTAL: ELECTRIC FEE
Lenders Name T
f' _ . '" 'J / PLUMBING PEI?
C•' Lenders Address QTY:
" - MLCIiANICAC I'ERMI'1' EF.
L) I certify that 1 have mad Nis application and stare that the above information is
correct.la rte 1 to cont with all cit and count ordinances and sesta laws relmin to PERMiTISSUANCH MECHANICAL FRE
` 8 DY wi city yo g
U rus idswengcolmsed raper forinspectio pta,ascmatives of rinds city to enter upon., CONSTRUCRONTAX
U FFGy77 about-memianed property for inspection purposes. AL'fP.R OR ADD TO MF,CH.
(We)ogre¢t s e,indemnify and keep harmless the City of Cupertino against
liabilities,] n. costs end aspens hichmey in coy way eccrueegvnt said Ciay AIR HANDLING UNIT(TO IO,IIW CFM)
in wnsequ a of gowning of Ni.pe it.
AIR HANDLING UNIT(OVER 10,000CFM)
Sigmmtirc ppli an omombo D e E%I IAUST HOOD LW/DUCT) PAIL13
IIAZARDOU' TER DISCLOSURE HEATING UNIT LTD 10IL"BTU) Date Receipt#
Will the applicant arfuum bun ding occupant store or handle htrnrdous material HEATING UNIT(OVER 100,000 BTU TOTAL:
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)7
❑Yes ID No VENTILATION PAN(S(SINGLENP p)
Will theapplicam orfuarebuildingoccupanmuequipmem ordevices whichemit
BOILER-COMP(3HP ORI BTU) ISSUANCE DATE
hazwdaus air comaminants as defined by the Bay Area Air Quality Management 'BOILER-COMP(OVFR WB, BTU)Utah, fia't's"3�!nn 1
is rm
❑Yee ❑Nn NEW RESIDENTIAL. .CH. SQ.IT.
I have read the harallous..solo[,requiamems under Chapter 6.95 of the V661 L g Av
California Health&Safety Cade.Sections 25505,25533 and 25534. 1 understand that
if the building does not currently have a tenant,that it is my responsibi lily to notify the
oaenpm l of the requirements which must M met prior to issuance of v Cernfiome of
Occupancy, lA
Owner or amhadred agent Data TOTAL: ISSUED BY:
OFFICE