26647 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 1111.1.1Nir6LELTITICA. PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 26647
BUILDING DIVISION ,/ BUILDING'PROJECT IDENTIFICATION
BUILDING ADDRESS: A/A DNITN LOTX SAM ARY NO. APWN�)UH�MLDXFE
OWNIfR^/dA`/xMf!: PHO N-C/•/� CONTR 'S ME: LICN30:�( N/C
ARCHI'I'EC17MGINI?IiR: LIC O: ADDRESS
e&d ❑
CON'T'ACT: PHONE: e`t. muB.Slhefssr '. : ,ng'UILDING PERMIT INFO
Q'I Y.';}' ECF.GTRfffRMITw& FEES
S' i;4.'s 1 e 6 °_T' ' BLDG ELECT PLUM MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
pCZ I hereby affirm that lam licensed anderprovisimmufChapter9(commencing with TOB DESCRI ON
td00 Section 700 of Division 3 of to B loess and Professions Code,and my license is in PANELS
Fy�l+l� full force nd of I ' UPT02MAWS
6F zVz p Llwrec lass Lia.p
"el Date Contractor 201-IOOOAMPS
Z�NZ A CHITECISDF.CLARATION OVER I"AMPS SQ.FT.FLOOR AREA S/SQ,FT.
Oz'-'p IunJemmnJ my plans Ghali b.used a5 public recnMs.
Ftit:WJ SIGNSELECTRICAL
6 EJ Licensed Profeasi...I
E �W< OWNER-BUILDER DECLARAT ION SPECIAL CIRCUIT C.
a�j4�OyU 1 hereby action that I am exempt from the Commctors License law for the
W 3R.y following mason.(Section"1031.5,Business and Professions Cade:Any city or county TEMP.M RPOLE MST.
I which requires a
Fo f5� perant to construct,alter,improve,demolish,err repair any s rectum
Lw}� prion.its issuance,410 hophars theepplichdfor such permit 1.Bleaaigned samment POWER DEVICES
0 that he is licensed pursuant to the Provisions of the Contractor's License Law(Chapter
aa 9(e.mmervin Ih Section 7(h of Di vision 3.fthe Business and Professions Code SWIMMING POOL ELECTRIC
W1oly &wI ) ) n�V��AttI��ATATION
ly-m Sechat tion 7031.5 by myap romandate Permitsbjthe
ctsalleged exempti to civiny l
of OUTLETS-SWITCHES-FIXTURES
ZQ not Section L5 by hundred
undre dolrtfar$30(d.Permit subjects the applicant ecivil pcnehy of
not more than Evethepm l J.Ilora yemp.
Q l,ssownerofthe NEW RESIDENTIAL ELE
❑ proructuermycmtended withwegesutheir sole eompensiiess S'I'ORII?S TYPE CONSTRUCTION
will d.thewmk.andChdr:'I the he Comr-i of Licener.fwdoesfiared rsale(Sec.'IBan Business
mrd Pel,whabr ldhor The venin..,License law docs not apply m an owner of
ownem whoburldsorimprovcs Ihermoandwhodoesoath workoroseIfedthroughhis
employees,provided that suchimpmvememsarcnolimenJed.mffercd(.vale.If, OCC.GROUP RES.UNITS
however,the buildingor improvement is sold within one year of completion,theowner. TOTAL:
builder will have the burden of Forcing that he did not build or improve for purpose of
sale.) 31 .' -
❑ [.as owner afthe property,am exclusively commeting with licensed conuucu to QTLY Xr: `h ,'PLWNEING PERMIT., FEE' FLOOD ZONE APN
construct the project(Sec.70bL Business and Professions Code:)The Contractors %
License Law does not applyto anowncroftemperty who builds or improves thereon,and PERMITISSUANCE
whnconuactsforsuch pmjectswilhacont=for(e)licensedpumctmtrothc Cmuoctor's ALTER-0RAIN&VP,NT-WA'rF.R(PA)
License Low. FEE SUMMARY
❑ I am exempt trade-Sec. ,B&P C for thin reason BACK FLOW PROTECT'.DEVICE O E,S
SANITARY Y N
Owner Date - RECEIPTX
DRAINS-FLOOR,ROOF',AREA,COND.
WORKMAN COMPENSATION DECLARATION SCt100L'fAX Y_N
[y�lherchy effmllhallhavea cenifiwm of consent whelf-imme,maeeniftcuteof IXTURPS-PER TRAP r RECEIP #
Worker-Compensation Brsummeor a entified copy thercof(See.3800,fab C.)which PARK FEE Y
covendlem I e'q ode permit GAS-EA.SYSTEM-I INC.4 OUTLETS REC..IPfp
Policyp ! BUILDING DIVISION FEES
Company a l /
❑ Cmifial r fumishal.
GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
c.PY is ereb
lifted copy is filed with the city inspection division. GREASHANDUSTRL WASTE INTHRCFPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
('Ibis section need not be completedHNe Permit is for one hundred dedlans pi 100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the Performance ofthe work for which this pemdt is issued,l shell THR WIVENT/ELECTIk
not employ any person in any mammy so as la became suhimI m the Workers /p/1a.T PAID
Contpenmtionlawsof CaliPomia. Dale WATERS EMfrREA'nNG /'I/1I1� Date RmcquX
Z APP1icar
0 NOTICETO APPLICANT If. making this Certificate of Eaemption,you should RESIDENTIAL PUSH. Q.FT. TOTAL:
E~ V) becomesubjecuo the Worker's Compensation provisions.fthe labor Cale,you must
� > foMwithcomply withauch provisions crtbis pemdt shell be,deemed revoked. BUILDING FEE
Q CONSTRUCTION LENDING AGENCY SEISMIC FRE
Z I hereby affimt thus hem is a construction lending agency for the Performance of ELECTRIC FEE
U O the work for which this pemtit is issued(S.,3097,Civ.Cy
Lk. Lender.Name 4 H PLUMBING FEE
Lenders Address MECIIANICAh PGEMIT= 'FEE
O U I clarify that 1 have read this application end state that the above information Is 63
�-t a c meat Iagreaocomply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
F" fn building construction,and hereby authorize representatives.fthiscity lumberman the
U7 above-mentioned Property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
rte- (We)agreem save,indemnify and keep hurmlesa the City of Cupertino against
liabilities,judgmems,costaxndexPemes which may in anywayaccmeageind said City AIR HANDLING UNIT G 010,000 CFM)
m e.mequence of the grunting of this permit.
AIR HANDLING UNIT(OVER III,O �M)
Signatureof APPliunnlConm¢mr Data I.XI IAUSTHOOD(W/DU
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNITE I0gIX10 BTU) Dam RmeiptIt
W ill the appliewa or fiwrc huilding accupum store c r handle hazmdous material
as defined by the Cupertino Munro.1 Code,Chapter 9.12,and the Health and Safety HEATING U OVER 10y0fif BTU) AL..
Cade,Section 25532(x)? /
❑Yes 0'16 VF,NT'II. ON FAN(SINGLE R1iSID) :T n a _
Will the epplicanmr fuwre building mcupant use eyvipmem or devices which emit
BO -COMP(3HPOR 100,000BTV) ISSUANCE OTATE
�hamrdous air comaminanls:Ix dere od by the Bay Arca Air Quality Management BOILER-COMP(OVER IOfBIO BTU) SEP 13 199
Diatdct? Dq�/
❑YO3 NEW RESIDENTIAL MECH. SQ.FT.
1 have read the treatments noterids requimmcnts trader Chapter 6.95 of he CII Y Ur VL+4'CN IIIV(J
ifteHealthy Safety Cale.Sectionsum,Ill25573and responsibility
Indio nerd that
California thebuildingdocs nmcIrteo Code.
ei ns 255thotitix my responsibilityr.stand the
O
ccupam of t e egtrir em ch must h mer
prior to issuance of a Cenificam of
Owner d acth.risetl agent Dam TOTAL: ISSUED BY:
OFFICE