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CITY OF CUPERTINO '- `" PHRMITNO. O
APPLICATION/PERMIT PLUMBING- MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIPICA'I'ION
26
BUILDING ADDRESS: //�� 11 '� `` SANITARY NO. APPLICATION SU13MIlTAL DATE
I12- Ixt.1' S V UNIT 40 LOT H
OEERS NAME 1 Oe,I PI{ONE:_ A'—�� CONTRACT'OR'S NAME: `O IC NO: N/C VCON 'BOLp
M,4-17- GY496r-
\RCHITIiCI'/IiNGINLGR: 1Y_1 LIIC N6: VY/ ADDRESS: /r' ❑
CONTACT : PHONE: �I QTY, - ELECTRIC PERMIT FEE BUILDING PERMIT INFO
n1O.> / PERMIT ISSUANCE BLDG 1.1011 PI. MECH
- ❑ ❑ ❑
LICENSED C RACTOR'S DEC RATION APPLIANCES - RESIDENTIAL /A��y
y I hereby affinndon l am licensed under provisionsof Chaprer9(coinmencingwidt BDESSCCRIT' [dew
O
Section 7")of Division 3 of the Business and Professions Code, and my license is in PANELS
I I
4pU1 rel l fume and effect.
I.icense Class Liar, UPTO 2101 AMPS
o-
Data Contractor 201-110X1 AMPS SQ. FT. FLOOR ARG S/SQ.IT.
Z ARCHITECT'S DECLARATION OVER 1000 AMPS
C I understand my plans shall In used as public reco ss.
SIGNS ELECTRICAL
Licensed Professional
U
OWNER-BUILDERexempDECGRArION SPECIAL CIRCUIT/MISC. '
I herehy nllirm that 1 nm exempt frau the Contractors License Lew for the
N following mass. (Section ]031.5, Badnessund Professions Code: Any city or county TEMP. M III I. OR POLE 1'.
which requires a permit to construct, eller, improve, demolish, a repair any atruclure
pomrto its issuance.ulso requires lheepplicant fursuch permit m fileaeignedsutement 1'OWf:R DEVICES Q I
pthat he is licensed pursuant the provisions ofthe Contractor's License Law (Chapter SWIMMING POOL ELE 1 , a
9 (commencing with Section 1") of Division 3 of the Business and Professions Cale) VALUATION
y or that he is exempt therefrom and the basis for the alleged exemption. Any violation to
Section 7031.5 b PP I yrr 011TLE15 SWITCHES-PIXTURF.S
y any upplicam far u #coati subjects the n licum m a civil nnnh f
not merethan live hundred Jolbn (8.500).
.01
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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❑ 1.asownerof1hepmarty,ormyemployeeswlthwagesaslheirsolecompensation.
NEW RESIDENTIAL LECTR _SQ. PI'.
STORKS
TYPE CONSTRUCTION
will do the work, and the structure isnal intended oroffered f aside (Sm. 7044, Business
Card Professions Cale: The Cmatmnmrs License Law does not apply to an owner of
pmp nywhobuildsorimpmves Nereon,andwhodoessuch work himsclforthrough his
nemployeex,provided that such impmvemersare not imendedoroffated forsals. If,
OCC GROUP
RES. UNITS
TOTAL .
however, the hailding ter improvement is sold within one yearofcompletion, the owner.
builder will Inve the burden of proving Ihut he did not build op improve for purpose nl'
QTY.PLUMBING PIiRMIT FEE'
de.).
❑ I, as owneroflhepropenY,amen<Iusivdyconlradingwilhlicensea cononnonm
F100O LOWi
APN
omtrvet the project (Sec. 7044, Business and Professions Crde:) The Commcmr's
License Lawdoes w
not applyto anonerorproperty who builds or improves thereon, and
PERMIT ISSUANCE
whocommetsfor such projects with a contmemis) licensed pursuant to the Contractors
License Law.
ALTER
FETE SUMMARY
❑ 1 nm exempt tinder Sec. , B & PC for this reason
BACK FLOW PROTECT. DEVICE'1'
IDE FE ,
SANITARY Y N
RECEIVI'p
Owner [)are—DRAINS-IIAOR,
ROOF, AREA, COND.
WORKMAN COMPENSATION DECLARATION
SCHGOLTAX Y N
❑ Ihertby effinm lhetlhaveecmificam of cunsenno elf -insure, ore anificate of
Wnhen'CompenwtionlnsumnaoracenifiMdc thereof(Ss 3g00,Lab C.)which
FlXTURFS - PER TRAP /
RECEIITp
PARK FEE Y N
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
covers all employee's under this permit.
Policy N
RECEIPTN
BUILDING DIVISION FEES
Company
❑ Cendicd cmpy is hereby famished.
GAS - EA. SYSTEM-OVHR 4 (HA)
PLANCHBCK FEE
GRFASEANDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GRFASETRAP
SOILS FEE
SEWER -SANITARY- STORM EA. 2101FT.
ENERGY WE
(This wmion need not be completed ifthe pemtit is for one hundred dollars ($ 100)
or lass.)
HEATER WNP.NT471.liCl'R
. Icenifflon intim pc,formancenfihe work for which thispc.it,s issued, lahollWAICR
not employ any person in any manna so as In become subject a the Worked
PAID
Conirnsationl.awsof Califomia. Date
ll
Applicant
A'E., YSTENVIREAI'ING
Date Receipt#
making this Certificate of F.xempdun, you should
W RESIDENTIAL PLMB. SQ, FT.
TOTAL:
become subject to the Worker's O mpenealion provisionsof the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm Ihuuhere is a cnextraction lending agency for the performance of
the work far which this permit is issued (See 3100, Civ. C.)
Lender's Name
TO
ELECTRIC FEE
Lenders Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
1 certify that 1 have read this application and state that the above information is
l agree to comply with all city and county ortlinances and state laws printing In
PERM IT ISSUANCE
MECHANICAL FEErrect.
built ingeonsnuolinn. and hereby uulhorize representatives of dris city to enter upon the
above-mentioned properly for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
We) agree to save, indemnify and keep hamdess the City of Cupertino against
liabilitics,judgmems,rita. and expenses which may in any wnyacenteagainsl said City
AIR HANDLING UNIT (TO 10,000 CFM)
ina ff he granting.f this pc.iv
a/ // J� _ \ Y-21fS
AIR HANDLING UNIT (OVER IO,000 CFM)
Signature of plliicum/Commnor Duct
EXHAUS"f HOOD(W/DUCD
PAID
HEATING UNIT (TO 100,0010 BTU)
I IALARDOUS MATERIALS DISCLOSURE
Date Rueipt#
Will the applicant or form building occupant store or handle htuardous material
as defined by the Cupertino Municipal Cale, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER IIXI,IXkT RTU)
Cade. Section 25532(a)?
C, Yw ❑ No
VEWI ATION PAN (SINGLE RESID)
Will the applicant nr fumm bu Tiding acupant use equipmentnnlevices which emit
BOILER - COMP IMP OR 110,000 BTU)
ISSUANCE DATE
BOILER- COME (OVER 100,000 BTU)
�azvtlous air contaminants as defined by the Bay Arca Air Quality Management
aiamet?
❑ Yes ❑ No
P
NEW RESIDENTIAL MECH.—SQ. FE
1 have read the h srdous materials requirements under Chapter 6.95 of the
Califomia I Icalth &Safety CMe. Semiuna 25505.255JJ and 255J4. I undersand that
ifthebuildingdacnutnients yhoveotnnm,lettit rloireuancebllitymnotify the
' O
0
Occupant of the royulremcros whlnh nmxl he met prior to iaxmnce of a Cenifiwm of
Occupancy.
��" 1 l'
ISSUED BY: J I r p
Owner or autllmdzed agent Data
TOTAL:
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