26264 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-EL CT'RI AL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL ID _ 26264
BUILDING DIVISION BUILDING PROJECT WENT
BUIL)INC AI ip } SANITARY NO. APPLICATION��,SUBBM��'fITAL DATE.
C UNITk LOTH
O PHONE: CONTRAC9' R:S NAME: LIC NO: f l
NIC CONTROL k
IkRCHITECT/ENGINEER: .LIC NO: AD ESS: ❑
CONTACT: PHONE:
QTY. .ELECPRICPERMIT FEE ,BUILDING PERMIT,INFO
IiL eCT PLIl�IB MECH
PERMIT ISSUANCE /
El
LICENSED CONTRACTORS DECLARATION of Ch ier9 APPLIANCES-RESIDENTIAL JOB DESCRII' N ek"w�.�.y'�^,
EJ00n�z Iherebya1'Division
amlleensedinss and Professions
Ohaple anda,,¢cense with . bF\1l „ 45fr.w
p1 O0 full fon7Wtl)efctvision3of the Business end ProfessionsCWe,and my license is in PANELS
Y full force and effect.
Qz License Class Lic.K UP TO 200 AMPS
y 6 y Dale Contractor 201-1000 AMPS
Z0qb ZZ ARCHITECT .S DECLARATION OVER IOIXIAMPS S .FLOOR AREA VSQ.PT'.
OZM I understand my plans shall be used as public records.
p,mF SIGNS ELECTRICAL
,�I Licensed Prnfesviannl
It
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MI �q
O 4 F 1 hereby affirm that I am exempt from the Contractors License Law for the �I` x s up.•�1
0.S:l following,utson.(Section 9031.5,Business and Professions Code:Any city or county TEMP.METER OR POI .INS' sI v
C< which raqu tas a permit to consumer,alter.improve,demolish,or repair any structure
priorto its issuance,also requires the applicant horsing permit to file a signed statement POWER DEVICES
pal�m'p p that he is licensed pursuant to the provisions of the Contractor's License Law(Chager
a ads 9(conm¢ncingwith Section 9000)of Division 3 ofthe Businessand Professions Code) SWIMMING POOL ELELTHC VALUATION
jWa] or that he is exempt herefrnm and the basis for the alleged exemption.Any violation of pUTLLTS-SWITCHES
Section 70315 by any app]Icon for a permit subjects the applbcam toacivil penalty of
Ono than Eve hundred d011ars(S500). NEWRESIDENTIALELECTR5 .FT.
m owneroftheprop oy,ormyempinyeeswithwagesastheirsoleconi enation, Q STORIES TYPECONSTRUCfION
y3� Il dothe work,and lhestructure isnot amended reoffered forsaie(Sec.7044,Business
ad Professions Code:This Carapace,a License Law does not apply to an owner of
propertywhobuildsorimproves thereon,and whodoes such workhimmiforthrough his
rwnemployecs,provitled that such improvements ore m0timm�dea roofferedforsale.If, OCC.GROUP RES.UNITS
however,the building or improvement is sold within one yearofcompledon,the owner-
builder will have the burden 0f proving that he did not build or improve for purpose of
sale) ,. < .. r
❑ has owneraOha propetty,am exclutivelyaintraating wnhl wised contractors to Q uii PLUMBING PERMIT= „y E$E' NLOOD ZONE Apry
container the project(Sec.9044,Business and Professions Cade:)The Contractors it
License Lawdoesmmapply roan 0wnerofpropmy whobulWsorimprovesthereoo,and PERMITISSUANCE I
whownveds forsuch protects wish n eorloupo(s)licensed Iursram mme Contractors
License Law. ALTER-DRAIN&VENT-WATER(EA) „ bFEE.SUMMARY: q' q '
❑ 1 am exempt under Sea so
,B&P C for this man BACK FLOW PROTECT.DEVICE a OUTSID.FE.ES
Owner Date
SANITARY Y N
RECEIPT N
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATIONod sucl DECLARATION SCHOOL TAX Y N
❑ en'CoyaffrmlhnIlhrance or i certified
copythenod(Snsara0,Lab C.) Michossw XTURES-PF.R TRAP RECEIPTN
Workers'Cnmpensa[ion lnsurnnverrvc0rtifee copy Thueaf(See.3g00,Lab C.)which PARK FEE YN
covers all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT 4
Policy b BUILDING DIVISION FEES
Company
❑ Certified wpY is hereby famished. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEF.
❑ Certified copy is filed with the city inspection division. GREASE/INDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(Thissectiom need not ba completed ifthepertnp is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
to less.)
Iwn]fydial in the parfernareeofthe work for which this penult is issued,Isbell WATER HEATER W/VENT/ELECTR
am employ any person in any manner s0 m m become tableau no the WorkersPAID
Compensation Lawsnf California. Date WATER SYSTEM/TREATING
s7+ Applicant Date RecciplN
Q
7 C) NOTICE TO APPLICANT:If,after making this Certificateof Exemption,y..should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
E"' N become subject to the Worker's Compensation provisions of the Labor Code,you muss _
forthwith comply with such provisions car this permit shall be deemed revoked. BUILDING FEE
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that there is it construction lending agency forth¢performance of T ELECTRIC FEF.
U Q the work for which this permit is issued(Sec.3099,Civ.C.) _.
W. Lenders Name y . f y,
F Lender,nearest QTY. @s .MCCHANICALPEi4ft .k +FEE' PLUMBING PEE
U I acidify Ihol 1 have read this application and state that the above information is -
�"' a correct. Iagree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
U Z ounwangcennrtandI pnndheehyaathonzererives. etivee of thio spy menterupm the CONSTRUCTIONTAX
U 'z above-meagred Impurity for inspection purposes. ALTER OR ADD TO MECH.
r-r (We)agree nt save,indemnify andws keep harmless the Cly of Cupertino against
inconsequence
of the
costs an I (theses which may inany way nccrueagvnau said City AIR HANDLING UNIT(TO IO,OW CFM)
consequence o[The grumi flhis permit.
goklk HANDLING UNIT(OVER 10,000 CPM)
slinfortumiffApplivion/Cmatorrun Dat EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt is
Will the applicant or future building occulinlsmre or handle hazardous material HEATING UNIT(OVER IBB000 RTU T AL
as defined by the Columbia Municipal Code,Chapter 9.12,and the Health and Safety )
Gide,Section Yes x)? VENTILATION PAN(SINGLE REBID)
❑Yes ❑No
Will the appllevmoA'mare building Ovwpertuse equlpmontordeviws which emit ♦
BOILER-COMP(SHP OR I00,WO BTU) ISSUANCE DATE
v� tions air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) Iq D
Moet?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have read the hazardous materials requirements under Chapter 6.95 of the 190A
California I Iealth&Safety Code,Sections 25505,25533 and 25534. 1 understand that v
If the building dues not currently have it tenant,Thal it is my responsibility to nollfy the
occupmn of be requiretnents which must be met phis,m imposed of a Cemifieem of Q��U, CUrtFt I IlY
Occupancy,
U
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-EL CT'RI AL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL ID _ 26264
BUILDING DIVISION BUILDING PROJECT WENT
BUIL)INC AI ip } SANITARY NO. APPLICATION��,SUBBM��'fITAL DATE.
C UNITk LOTH
O PHONE: CONTRAC9' R:S NAME: LIC NO: f l
NIC CONTROL k
IkRCHITECT/ENGINEER: .LIC NO: AD ESS: ❑
CONTACT: PHONE:
QTY. .ELECPRICPERMIT FEE ,BUILDING PERMIT,INFO
IiL eCT PLIl�IB MECH
PERMIT ISSUANCE /
El
LICENSED CONTRACTORS DECLARATION of Ch ier9 APPLIANCES-RESIDENTIAL JOB DESCRII' N ek"w�.�.y'�^,
EJ00n�z Iherebya1'Division
amlleensedinss and Professions
Ohaple anda,,¢cense with . bF\1l „ 45fr.w
p1 O0 full fon7Wtl)efctvision3of the Business end ProfessionsCWe,and my license is in PANELS
Y full force and effect.
Qz License Class Lic.K UP TO 200 AMPS
y 6 y Dale Contractor 201-1000 AMPS
Z0qb ZZ ARCHITECT .S DECLARATION OVER IOIXIAMPS S .FLOOR AREA VSQ.PT'.
OZM I understand my plans shall be used as public records.
p,mF SIGNS ELECTRICAL
,�I Licensed Prnfesviannl
It
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MI �q
O 4 F 1 hereby affirm that I am exempt from the Contractors License Law for the �I` x s up.•�1
0.S:l following,utson.(Section 9031.5,Business and Professions Code:Any city or county TEMP.METER OR POI .INS' sI v
C< which raqu tas a permit to consumer,alter.improve,demolish,or repair any structure
priorto its issuance,also requires the applicant horsing permit to file a signed statement POWER DEVICES
pal�m'p p that he is licensed pursuant to the provisions of the Contractor's License Law(Chager
a ads 9(conm¢ncingwith Section 9000)of Division 3 ofthe Businessand Professions Code) SWIMMING POOL ELELTHC VALUATION
jWa] or that he is exempt herefrnm and the basis for the alleged exemption.Any violation of pUTLLTS-SWITCHES
Section 70315 by any app]Icon for a permit subjects the applbcam toacivil penalty of
Ono than Eve hundred d011ars(S500). NEWRESIDENTIALELECTR5 .FT.
m owneroftheprop oy,ormyempinyeeswithwagesastheirsoleconi enation, Q STORIES TYPECONSTRUCfION
y3� Il dothe work,and lhestructure isnot amended reoffered forsaie(Sec.7044,Business
ad Professions Code:This Carapace,a License Law does not apply to an owner of
propertywhobuildsorimproves thereon,and whodoes such workhimmiforthrough his
rwnemployecs,provitled that such improvements ore m0timm�dea roofferedforsale.If, OCC.GROUP RES.UNITS
however,the building or improvement is sold within one yearofcompledon,the owner-
builder will have the burden 0f proving that he did not build or improve for purpose of
sale) ,. < .. r
❑ has owneraOha propetty,am exclutivelyaintraating wnhl wised contractors to Q uii PLUMBING PERMIT= „y E$E' NLOOD ZONE Apry
container the project(Sec.9044,Business and Professions Cade:)The Contractors it
License Lawdoesmmapply roan 0wnerofpropmy whobulWsorimprovesthereoo,and PERMITISSUANCE I
whownveds forsuch protects wish n eorloupo(s)licensed Iursram mme Contractors
License Law. ALTER-DRAIN&VENT-WATER(EA) „ bFEE.SUMMARY: q' q '
❑ 1 am exempt under Sea so
,B&P C for this man BACK FLOW PROTECT.DEVICE a OUTSID.FE.ES
Owner Date
SANITARY Y N
RECEIPT N
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATIONod sucl DECLARATION SCHOOL TAX Y N
❑ en'CoyaffrmlhnIlhrance or i certified
copythenod(Snsara0,Lab C.) Michossw XTURES-PF.R TRAP RECEIPTN
Workers'Cnmpensa[ion lnsurnnverrvc0rtifee copy Thueaf(See.3g00,Lab C.)which PARK FEE YN
covers all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT 4
Policy b BUILDING DIVISION FEES
Company
❑ Certified wpY is hereby famished. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEF.
❑ Certified copy is filed with the city inspection division. GREASE/INDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(Thissectiom need not ba completed ifthepertnp is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
to less.)
Iwn]fydial in the parfernareeofthe work for which this penult is issued,Isbell WATER HEATER W/VENT/ELECTR
am employ any person in any manner s0 m m become tableau no the WorkersPAID
Compensation Lawsnf California. Date WATER SYSTEM/TREATING
s7+ Applicant Date RecciplN
Q
7 C) NOTICE TO APPLICANT:If,after making this Certificateof Exemption,y..should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
E"' N become subject to the Worker's Compensation provisions of the Labor Code,you muss _
forthwith comply with such provisions car this permit shall be deemed revoked. BUILDING FEE
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that there is it construction lending agency forth¢performance of T ELECTRIC FEF.
U Q the work for which this permit is issued(Sec.3099,Civ.C.) _.
W. Lenders Name y . f y,
F Lender,nearest QTY. @s .MCCHANICALPEi4ft .k +FEE' PLUMBING PEE
U I acidify Ihol 1 have read this application and state that the above information is -
�"' a correct. Iagree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
U Z ounwangcennrtandI pnndheehyaathonzererives. etivee of thio spy menterupm the CONSTRUCTIONTAX
U 'z above-meagred Impurity for inspection purposes. ALTER OR ADD TO MECH.
r-r (We)agree nt save,indemnify andws keep harmless the Cly of Cupertino against
inconsequence
of the
costs an I (theses which may inany way nccrueagvnau said City AIR HANDLING UNIT(TO IO,OW CFM)
consequence o[The grumi flhis permit.
goklk HANDLING UNIT(OVER 10,000 CPM)
slinfortumiffApplivion/Cmatorrun Dat EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt is
Will the applicant or future building occulinlsmre or handle hazardous material HEATING UNIT(OVER IBB000 RTU T AL
as defined by the Columbia Municipal Code,Chapter 9.12,and the Health and Safety )
Gide,Section Yes x)? VENTILATION PAN(SINGLE REBID)
❑Yes ❑No
Will the appllevmoA'mare building Ovwpertuse equlpmontordeviws which emit ♦
BOILER-COMP(SHP OR I00,WO BTU) ISSUANCE DATE
v� tions air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) Iq D
Moet?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have read the hazardous materials requirements under Chapter 6.95 of the 190A
California I Iealth&Safety Code,Sections 25505,25533 and 25534. 1 understand that v
If the building dues not currently have it tenant,Thal it is my responsibility to nollfy the
occupmn of be requiretnents which must be met phis,m imposed of a Cemifieem of Q��U, CUrtFt I IlY
Occupancy,
U
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE