26655 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPFRTINO BUrLDIN(:-ECECT - PERMITNo.
APPLICATION/PERMIT PLUMBING-MECHANICAL /N/1 /\F6 5 t�
BUILDING DIVISION BUILDING PROXIMA IDENTIFICATION c FVC
BUILDING ADDRESS; SANITARY NO. MI'LICATION SUI{MI'IT'AL DAII3
223 r7T UNI'1x LOTH
OSWsANN�HIi NAME: �.,�,� 1�n../J' I't10Nli: CON'IJkpCI'ON'S NAMG: LIC NQ
r-1 NWT. 5✓19Aa 1)eek ZSZ -7GO7 rJ� (� IJ NIC CONTR01.#
' ARCIII'ECIENGINEER: LIC NO: ADDRESS: ❑
1
GS IN
ell
/ 115 / F6Z—C15FS QTY. ELECTRIC PERMIT FEF; BUILDING PERMIT INFO
�IOOVV IZ `T' / / �7 F1610 PL B MECH
C� I PERMIT ISSUANCE � ��j[` ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL 'T�'��
nal I hereby affirm that l am licensed underprovibionsol'Chaprer9(commenting with 1- JOB D RIY,�# "
14WO Second`W)eo`DivisionSof Ore Biennials and Professions Cole,and my license is in PANELS
pQ„Zu] License CL Lic.# J�� UP TO 200 AMPS 1
wM h Dae Conaamm 201-18(10 AMPS
Z OHZL, ARC1113TCT5 DGCLAR ON OVER IOW AMPS SQ.FT.FLOOR AREA S/SQ.FT.
OZ-0
I understand my plans shell be used as Public records.
F in 1-� SIGNS ELECTRICAL
QYf:j Licensed Professional u�
0.yvw< OWNIiR,BUILDF,R DECLARATION SPECIAL CIRCUIT/M19C. ` � -i� n� ..� r�
O°H I hereby d1irm that I am exempt from the Convenors License Law for the l I\ / C„// I Ih
iw3 a y fallowing mason(Section 7031.5,Business and Profbssions Code:Any city or county TEMP.METER OR POLE INST. L V d
u' which requires a permit 10 connmct,dual,improve,dcmalish,or repair any,svucrum
T�
Force,i's issuance,-Ism requires meapplicant forst perand to fileasignednatcment POWER DEVICES
W OO that he is licensed pursuant m the provisions of me Contractors License Law(Chapter ATE
E
d o 9(annmcncingwhIT Sation9W10o1'Division 3ofine Business and Formation,Cartel SWIMMING POOL ELECTRIC VAL A'1'ION
1y_y ar that he is exempuhcrefmmand the basis for mealleged compliant.Any violationof O'yk/y
1-•_ZQ Section 7031.5 by any applicant for a permit subjects the aprz ITIL
plianT toacivil penalty of OEI'S-SWITCHES.FIXTURPS
� `NN
D
not more man live hundred dollar(5500).�. ❑ Losow aroftheproperty,ormyemplayees with wagesas theirsolecompereatiNEW RESIDENTIAL ELECIR _SQ.FT.an. STORIES TYPECONS'rRUCTION
y3°_° willda the
le(Sec.7W,BmJr
work,unJ the structure ivtm imenJOJ proffered for suess
and Professions Code:The Con eremr's License law docs not apply to an owner of
property who builds or improves thereon,and whadces such work himrelf or through his
own employees,provided thmsuchimprovemen¢am not imendelorbffered formle.If, IOCC GROUP RFS.UNITS
however,the buildingorimprovemcm is sold within one year ofcompletion,the owner- TAAt F94l
holder will have the burden of proving that he did not build or improve for parpase of
sale.).
❑ I,asownerofthepmperdy.mnexausivelycontrnctingwimlicensedcon=tonin QTY. PLUMBING PERMIT FEE FLOODZONE APN
compact the project(Sec.7014,Business and Professional Code:)The Caron is
Lieensel,awdoesnntapplymannwnerofpropertywhohuildsorimpmvbsthcran,end sk PERMIT'ISSUANCE
whocooducts forsutlT projects will,asmntmctor(s)licensed pursuanun the Conmoctor's ALTER DRAIN&V13NT-WATP.R(f?n
License Low. ) FEE SUMMARY
❑ 1 um exempt under Sa. ,B&PC for this maws BACK PLOW PROTECT.DEVICE OUTSIDE FEE
Owner - Date SANITARY Y_N
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. RF.CRII"f#
SCHOOL TAX Y N_
❑ Ihemby affirm theTl have a cenlfienre nfaccsenno self-insom.,a cenificme of FlXTURES-PER TRAP RECEIPT#
t,Waden'Compensation Boorman.certifiedbopy meteof(Sa.3600,Lab C.)which PARK FEE Y N
n all atimb,e2al under this peort' GAS-GA.SYSTEM-I INC.4 OUTLETS BUILDING
#
Policy p BUILDING DIVISION FEES
Companyf'1{{��
❑ Ccrfi" copyiahadbyfummh� GAS EA.9Y9TP.M-OVER4(P.A) PLANCHECK I11i
P110c7ified copy is Bled with the city inspection division. GREASEWNDUSTRI.WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREAS13TRAP SOILS FEE
INSURANCE
rThissation neeclowbecompleted ifthepermit is foromhommaldo11nm(f100) SEWER-SANITARY-STORM F.A.2001'T. ENERGY FEE
odea.)
I tardily That in the perfornance of Ne work for which this permit is issued,l shall WATER HEATER W/VENT/ELECI'R
not employ any person in any manner so as ,,become subject to the Worked' PAID
z
Compensation Laws of California. Date WATER SYSTENUTREA'LING Uera Neceipl#
Q Applicant
z0 NOTICE TO APPLICANT.If,after making this Certificate of Exemption.you should NEW RPSI DENTIAL FINE. SQ,ET. TOTAL:
^F to became subject to the Worker's Campensauon provisions of The Inbar Code,you mast
t� forthwith comply with such provisions or this permi t shall be deemed revoked. BUILDING
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a z Ihereby affirm Thai hem is a comaunlon lending agency for the performance of ,}
U O the work for which this pcmdT is issued(Sec.3097,Civ.C.) .: L ELECTRIC FEE —\ r
Lts lender',Name
Lenders Address QTY. MECHANICAL PERMIT FBI: PLUMBING FEE
U I certify mm 1 have read this application and stare that the shove information is
building Iagree tocomply hemallciryatM county ordinances and natelaws mlmingm PERMIT ISSUANCE MECHANICAL PTF.
UZ amerngconmad property
hor impactionpss repmsdnmriveaorlM1iscity[p eaternpnn the CONS'IRUCIONT'AX
U z ubnv(We)igree propenyforitnpa and purposed. ALTER Oft ADD TO MI3CIi.
(000)agree nd rove,indemnify and keep huonless the City of Cupeninn against
Iiabilities,judgmenB,costsand expenses which moyin an weyaarve agunst said Ciry AIR HANDLING UNIT(T010,000 CFM)
nsey nee o(th ranting of this permit.
o
AIR HANDLING UNIT(OVER 10.(011 CFM) t tri
SlImMicil T Cnnuactar I1 rte EXHAUST HOOD(W/DUCT,
PAID
HAZARDOUS MATERIALS DISCLOSURE BEATING UNIT(TO IOq(OO BTU) Date Receipt#
Will the applicant or future building occupant store or handle hamrdous material ((EATING UNIT(OVER BB,WO❑'I'U) 'H]"
as dclined by the Cupertino Municipal Code,Chapter 9.12,and the Ilcalth uad Safety
Code,Section 25532(x)'!
Cl Yes ❑No VENTILA NON FAN(SINGLE RFSID) f
Will Theapplicumnrfmure building occup:mT useequipmem ordevices which emit
BOILER-COMP CHIP OR 100,000 BTU) ISSUANCE DATE
., hamnlonx ab conmmiaants as droned by the Buy Are.Air Quality Manogemem BOILER-COMP(OVER 100,000111 U)
DisvicR PAID p I D
❑Yex ❑No NEW RESIDFNIIAI.MECH. SQ.F1'. 1r i1
1 hove read 1110 hmmilois materials requirements under Chapter 6.95 of the eCV o
California Health&Safety Cade,Sections 25505.25533 and 25534.1 understind Thar
if the building does not currently have a tenant,That it is my responsibility To notify the tlVBtl
fin
poops..of The requirements which mull be met prior m issuance of a Cenumor of Tal l
Occnpanbp .n IITVU
Ownero,00ll izcJagent Date TOTAL: ISSUED BY:
OFFICE