26210 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING;F.LEC'FRI Al. PFRMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 26210
BUILDING,DIVISION BUILDING PROJKCI'IBE„N'fIBICATION
BUILDINGADDr 4 D`R�BSS: �.J SANITARY NO. APPLICATTO,,,NyyySUBMMIITTALDAIE
I O ss ,d- FI l c-t UNITN LOT#
O SNAM': PHONE: C RACTON'S NAM` LIC NO: 5 r -
NIC CONTROLp
RCHIIECUENGINEER: LIC NO: U SS:
L)s . Q..,9ns, u.! e ❑
CONTACT: PHONE: BUILDING PERMIT INFO
Q'I'Y. ELECTRIC PERMIT FEU.”
.BLDG ELECT' PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'SDI:C1ARA'HON APPLIANCES-RESIDEN'T'IAL
Oaz I hereby affirm that l am licensed underpmvisionsol'Chapier9(commencing with TOB DBSCRIPT N
POO
ta'u6L_t-� rSaedctiforce
and effect.
ruet.
ision J of tM1e Business and Professions Code,and my li<eme is in PANELS
License Class UPT020 AMPSNy Dom Contractor 201-II0 AMPS `
Z0,5 ARCIIITECTS DECLARATIONOVlili II11N1AMP - SQ:fT.FLOORARHA $/SQ.FP.
p'L'�G Innderxunul my plans shot(bo used as public reurtds. f�
SIGNS ELECT' ICM- „'
6yj Licensed Professional l..
as 0U OWNER-BUILDER DECLARATION SPECIALCIRCU'T/M SC_ �1 1 r t t l p1
KOaF 1 hereby mfimt that 1 am exempt from the Contractor's License Law for the Y1io�a
W3A following reamn.(Section 70315,Husiaeseand Profusions Code:Any city or county TEMP.METEN RP A11N9 L'J U
�Oj which rcquirusa permit tnrnn.sauct,alter,improve,dam+lish.ormpalrany etmctu¢
au�1YF prior mils imvana.,also requires the applicant forsuch pmmilla rile usignedandemem POWERDIiVIC S DAIE
µ)appm that he is licensed pursuant to provisions of the Conuaaors Licence law(CM1apmr
d%eLL 9(commencing with Section 700p)of Division 3 of the Business and Professions Code) SWIMM INC,PO C-TRIC---- '- VALUATION
µp_y or that he is exempt herefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant fora permit subjects the applicant to a civil penalty of OUTLET'S-SWITCHES-FIXTURES
gnot morethun fivehundrel Jnllors($500).
'p ❑ boarloans,,+ftheprol<ry,orntyemployceswithwagwuslbeirsolec.mpensallon, NEW RESID11WIALF,LECfR _SQ.FI'. - STORIES 9NPIi CONSTRUCTION
lad =e will do the work,and the meet me is not intended or offered far'We(Sol.7044,Business
and Professions Code:The Convectors License Law does a.,apply to an owner of
pmpery who builds.,balance.Ihereoq and who daes such work himself.,hrough his
ownemployces,MjyidMthat.stichimpmvementaumnotintendedorofferedforsate.If, OCC.GROUP RES.UNITS
however,the building or improvement is sold within one year ofcompletion,theowerr- TOTAL:
builder will have the burden.f proving that he Aid not build or improve for purpose of
sale).
❑ I.asownerofthepropery,amexclusivelycontrucdogwithlicensedconrrectontn QTY. PLUMBING PERMIT FEE FLOODZONE APN
control the project(Sec.)BW,Business and Professions Code:)the Contncmri
License Lawd«snot apply loan ownerefprti who milds.rimprovestherem,and PERMIT ISSUANCE
Licennsese Low.
whoLoforsuch projects with ucomrecmr(s7licenseJ pursuant tothe Commmor»
A1,9'IiN-DRAIN&VF.N'r-WATER(FA) FEFSUMMARY
❑ I am exempt under Sec. ,R&I'C for This,croon BACK FLAW PROTECT.DEVICE 9.I PEES
SANITARY Y_N '
Owner Date DRAINS-FLOOR,ROOF.AREA,COND. RECEIPTN
The
ca WORKMAN COMPENSATIONDECLARATION SCHOOLTAX YN_
❑ reby affirm that lhave ecertificam ofttmscm to self-insure.orecertificam of FIXTURIS-PERRAP RECEIVER
Workers'Compensation lnsumnoeor.canlfiul copy thmeof(Sec.75W,Luh CJ which 'fPARKII!II Y N
ors all employee's under this,moil. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPTA
Policy X BUILDING DIVISION IBIS
Company
CenifieJ copy is hereby fumishM. GAS-FA.SYSTEM OVER 4 BA) PLANCHECK MEE
❑
❑ CenifieJ copy is fileA with the city inspectiondivisi.n. GRFASrONDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICA9'Ii OF EXEMPTION FROM WORKERS' GRfASETRAP SOILS >I?I:
COMPENSATION INSURANCE
(Thicsenionnced natbecompletedifthepermit ivimenehmsred dollars($IW)
or less) SEWER-SANITARY-STONM fA.2WFT. ENERGY FEE
I certify0m inthe performance of Ne work far which his .it is issuM,(shall WATER MATER W/VENT/ELECTR
not employ any person in any manner so as to become subject to the Workers' PAID
O 2 CAompensalinnl.awsof C.1dooia Date WATER SYSTENVTRFATING Dore Receipt Is
Applicant
7 NOTICE'1'(l APPLICANT:If.after making this Cenificem of Exemption,you shouldNEW RESIDENTIAL PLMIL SR IT. 'TOTAL:
L•'•' .l-, become subject o the Worker's Compensation previsions of the labor Code,you must
f� 7 forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
4 �] CONS'T'RUCTION LENDING AGENCY SEISMIC ITE
Z I hercbyaffrm that here is a eonenation lenlug.,mcy for the performance of
U O the work for which this permit is issued(Sec.3099,Civ.C.) AI: ELECTRIC FRE
Lendeex Address
PLUMBING FEE
f-' Lenders AAdmss QTY. MECHANICAL PERMIT PEG
U I sanity the I have read this application and corm that @e above information is MECHANICAL FEE
correm. lagree locomply with all city and mmntyonitivececand sem laws trelating m PERMIT ISSUANCE.
L) % movengcationed property
hereby summit purposes,
ives.fthis city mcorer upon lM1c _
FU z move mentioned property for inspemion purposes. ACI'1?N OR ADD TO MIiCIL CONS'I'RUCIIUN TAX
(We)agree m save,indemnify and keepJta less the Gly of Cupertino against
in
abilitmajudgme oat expenses. dch yit y way accrue against said City AIR HANDLING UNITTr010,000 CFM)
g ng ofth'
p�200Z AIR IIANDLING UNIT(OVER I0,000 CFM)
SI XIAISOOD( /DUTlr
PAID
HAZARDOUS MATERIALS DISCLOSURE HEAS'ING UNI'PTO 100,M)BTU) Duro RcmF,k
Will the applicant or future building occupmt atom or handle hazardous melena( HEATING UNIT(OVER IIXI,(Xq BTU) TO
as defined by the Cupertino and Municipal Code,Chapmr 9.12, the Ilcalth and Safety
Coda,Section 25532(a)?
❑Yes ❑No VEN7ILA9'ION PAN(SINGLE RISID7
Will lhmt Iicanmrfumrc huildin equipm OOILI3R-COMP(3HP OR IIXI,OIXI BTU)
ISSUANCE DATE
pp d by 11,Bay ant orality an igM1 a it
• hazardous air amtuminants as defined by the Buy Area Air Quality Management
District? BOILER-COMP(OVER 10.1,000 BTU)
❑Yes ElNo NEW RESIDENTIAL MECII. SQ.FT. P A A
1 have road the hazardous materials requirements under Chapter 0.95 of the IJ
California l lcallh&Safety Code,Sections 25505,25533 and 25534. 1 understand that n/1R Fjn9 199
ifthe building does not currently have.tenant,that it is my responsibility m notify the
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
Overrnr wnhnnzM agate Date 'TOTAL: ISSUED BY: � Ju
OFFICE