26475 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO F1W.P1Ns-FI:FT7TRF7A p RALITNO.
BUIL
nINc nlvlslGry APPLICATION/PERMIT PIDMBINC.-MECHANICAL. 26475^ r
BUILDING PRf1JEITF IDEN'1'It'ICA'1'ION 6 4 7 5
RUILDI AI� � V'Voos s ` �I SANT"fARY NO. APPWCA'IION SUHMII'TAL DATE
LOTp� �V 6 �
O N' SNAMF.: PHONE: C R�AR�PNAM& LIC NO: li
��++LL1� g s S Q� Nrc CONTROL.#
�RCIIITF.Cl/ENGINIiER: LIC NO: DDRESS 4
JM�saer. q s,�. qs rr/ ❑
CON'IACf tt y/I'S\ C P ONC:- '.rk, � 3 ,g;}vy T.x g.)g•,gp X"gCG �r a -
Q S'L L ll-�f-� l / (q ._ LirGiQ(.� QTlp.it,1, iLBCTRIC PERMIT�k�"p, JFEE � �"BUILDING PERMIT INFO
/C ` ' PER Lp0 E PLUMB C
r1? 7 '• -�>((J� PERMIT ISSUANCE � ❑
LICENSED CONTRACTOR'S DECLARATION APpL1ANCE5-RESIDENTIAL
cSxZ I hereby affirm that Ian licensed underprovisionsofaapter9(commencing with JOB DESCRIPTION
Wes E Section]an1dafetDivision3of the Business and Professions Code,and mylicrnse isin PANFTq �a
,YU0 fall o 7000 effect.
Np
License Class Lic,p UP TO 200 AMPS
Dole Contractor
201-IOI%1 AMPS
FT.
F'r z ARCHITECTS DECLARATION SQ.FT.t1.O0R ARG
Oz� OVER 1000 PS $/SQ.
I understand my plans shall be used as public records.
40 � L—a—u ProbasounalSIGNS EL C
5 OWNER-BUILDER DECLARATION SPECIALCI I
Wq f- I hereby-Hmm that 1 am exempt from the Contractor License Law for the
3�afollowing od-Vm.(Section]o3L5,Business and Pmfeuions Code:Any city orwunry TEMP. POLE T.
L` 1 which requires a permit to construct,alter,improve,demolish,or repair any sWcon.
WQ prior to its issuance,nlsoregmres the applicant forsuch permnr fileasigned samment POWE EVICES
0.�Op that he is licensed pursuant to the provisions ofma Commnmis License Law(Chapter
Sa�ppa 9(coarcum ng with Section 7")of Division 3ofthe Busiaeasand Professions Cale) SWIMMING POOL ELECTRIC
W_N Or he is exempt therefrom and the basis for the alleged exemption.Any violation of VALUATION
Z Q Section 7031.5 by any applicant for a permit subjects the applicant In a civil penalty of OUTLET'S-SWITCHES-
not more than five bundles Jnllnrs($SIN)).
at"o 11I.usowneroftheproperry,ormyemployecswimwagesumcirsolecomprnsadon, NEW RESIDENTIAL ELECTR __SQ.FT. STORIES TYPECONSTRUCTION
3= will Jnthe work,and theswcwmis not imm�dedorof(area forsale(Stt.]M4,Bminess
and Professions Calc:The Contractor's License Law fees not apply to an owner of
propeny who buil&orimprovesihereon,andolo doessuch work himselfocthrugh his
eonemployees,provided that such imprvvementsma not intendedmraff,red tarsale.If, OCCGROUP FEE .USE TS
however,the building lir improven:eal is sold within one year ofecmplalon,the owner-
builder will have the burden of proving that he did not build or improve for Impasse of
sale.)
❑ 1--18 owner robe Property,umexclusively contracting with llcenaW ennvectort QPYa 9�SR 3a,1 tPCUMBING PERMIT; PER} FLOOD ZONE APN
cmmmvn the project(Sec.7014,Business and Rofesnons Cale.)The Commerce,
License Lawdoex not aPplYto an owncrofproNmy who buildsor improves thereon,and PF.RMITISSUANCE
who cmnvans forsuch projects with a emood cror(s)licensed pmsuanuothe Contrecrr's
License Lew, ALTER-DRAIN&VENT-W ;R EPA) - FEE SUMMARY
❑ I am exempt under Sec. ,B&P C far this reason
BACK FLOW PROTECT.DE 1 ? • 'EL:
Owner Dare SANITARY y__N__
nWORKMAN COMPENSATION DECLARATION DRAINS-FLUOR.R OND. RECEIPI'p
❑ Ihereb ffrmthm lhavenceniliculeofenmwnnoself=nsu SCIIOOL TAX y_ry__
Workers Comp nutionlnsuranceoracertifiedenpythereof(Sm,380Q1abC)whi<h FIXTURES-PER 6APif RHCEirr#
ewers nllemployee's under this permit PARK FEE Y N__
Policyp CAS-EA.SYSTRM-1 INC TLE S RE,CF it p
Company BIM I VI ONFFES
❑ Cenifiedcopyishersbyfumished. GAS-EA,SYSTEM-O EA) PLANCHECK
❑ Candied copy is filed with the city inspection division. GREASH/Us LWA. INT PTORO
GRADING IT
CERTIFICATEOMPE EXEMSATIO NSUON ROM WORKERS' OREASF.'IRA
COMPENSATION INSURANCE SO11.5
Ends'I'-need nm becompleted if ho permit is formal hundred dollars($100) SEWER-SANITor less.) STO .200F1 -
ENERGY FEE
I certify that in the performance ofine work for which Ws permit isfastback,IshWl WATER HEATER WIVFN IN
of emploY any person in any manner an m In became subject to the Workers
z Compensation Lawsof CalifornPAID
ia. Data WATER SYSTEMITREATING Dam miptp
O O Applicant
NOTICE.TO APPLICANT:If,ager making this Calificam of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT.
h become subject to the Workers Compensation provisions of the Labor Code,you must TOTAL: ,
7 fmnhwith comply with such provisions or this permit shall be deemed revoked. BUILDING IEE
W Q CONSTRUCTION LENDING AGENCYSEISMIC FEE O
Z 1 hereby affirm that then,is aconstruction lending agency
grncy for the perfomance lir
U O the work for which this permit is issued(Sec.3097,Civ,C.) TOTAL: ELECTRIC FEE �.
Lander.,Name
>1 V LenJels Address !MECHANICAL PERMIT- - � TEE PLUMBING FEE
>1W n l«mrr mm 1 have mean mats application ad sant that the name hibernation is � .. .
,r 6. nen, l agree to comply with all city and county ordinances and shale laws relating r PERMIT ISSUANCE" MECHANICAL FELL
py building consmction.and hereby aummae mpmaenativesof Nisciry menterupon the
z above-mentioned pmpeny for inspection purposes ALTER OR ADD TO MECH. l CONSTRUCTION TA%
(We)agree r save,indemnify and keep It less d¢Ci ape inn against
liabilities,jud ma.cnstsend as whic yin ayaca ag misaid Ciry AIR HANDLING UNIT(TO IBhNNCFME
in consortia fthe matirlpoft panni
IRHANDLINGI1NIT(OVFRIO.( GCM)
,,a re plicant/Contrac a Date "HAUSTHOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS occAfSt.l re mSURE HEATING UNIT('1'O IW,WO BTU) Dote Receiptp
Will the applicant m fume building rccupa p erre or and t e ficaMous d Safer l
as Code,
Section
the Cup<nino Municipal Gde,Chapter 9.12.and the Hrann and Safely HN.ATINO UNIT(OVER I(NI,fNM)B'I'U) L
Cafe,Section 23532(a)f
❑Ycs Cl No VENTILATION FAN(SINGLE RESIDE `
Will the applicantorfmure buildings:cuprnt useequipmentordevices whichemit BOILER-COMP 0HP OR 100,000 BTU) ISSUANCE DATE
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER I ® �
m l l W,U00 B'I'U)
'trial?
c EI yes ❑No
I have read the hazadous mammalsNEWRESIDENTIAL MECII. SQ.FT.requirements under Chapter 6,95 of the AUG 3 0
Califomin Health&Safety Code,Sections 25505,1!5533 and 25534. 1 understand met {a �^
Oce.pehe ilding doesnot emoren0y hu vennnonh that it is my rtspu nsl6lity to nrnify the
occupant of the requirements which most be met prior r issuance of a Certificate of
a<upancy. UJ- r r•
r "r 11
Owner ter umhnnxd agent
OFFICE T
ISSUED BY: