26027APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
OF CUPERTINO BUILDIN17 HLECIA
APPLICATION/PERNIIT PLUMBING - MECIIANICAL
BUILDING DIVISION BUILDING PROJECT IDF-NI'IFICAI ION
PERMITNO.
26027 � O /�
G
NG ADDRESS:
SANITARY NO.
APPLICATIIOOONN SUBMITTAL DATE
W Nfl'# LO Y#
;ARCH"ITECTIENGINEER:
V `
/� �^ �1
SNAME: S,SI / itsri�li
ONIHACI�Ii NAME: fr �4N����
N/C
CONTROL. #
LIC NO:
CONTACT PHONE:
-
QTY. :r BI:EGfRIOPHRIv1IT,. FEE
HUILDING PERMIT INFO
BLDG ELECT PLUMB M C
" .. r, j I ' '
PERMIT ISSUANCE
El 11 1:1
LICENSED COM'RACfOR'SUECLARA'TON
I hcreb (firm ohmlam licensed and« (Cha mr9 commrncin
ya proviairnaa p f gis
APPLIANCES - RESIDENTIAL
TOB DESCRIPTION
PANELS
UP TO 2W AMPS
$emiorce and fDivisinn3ol'the Business and Profession Code. and my licLLenu is in
in
fall
license Class r` Liu.p
Limumelars�. �!'
Date Commctor Q
ARCHITECTS DECLARATION1000AMPS
1 understand my plws..,hull be axed as public mounds.
'
20i -PAID AMPS
OVER
SQ. FT. FLOOR ARCA $/SQ. PI'.
SIGNS ELECTRICAL
p I^
"q\ L
Illi
Licensed Profexsiunal
OWNER -BUILDER DECLARATION
SPECIALCIRCUITMSC.
Gf5
1 hereby affirm that 1 um exempt frmn the Convectors License Law for the
j O
TEMP. METER OR POLE INST.
Billowing reason.(Semon7031.5, Business and Professions Code: Any city or county
IY
U
which mqubcs a permit to concoct, alter, improve, demolish, or repair any structure
Ills\/[
prionoits issuance, also requires the npplicam for such permiao filceaigned eutement
POWER DEVICES
that he is licensed pursuant to the Purolator, of the Co ermtor's License Lew (Chapter
9(commencing with Section, 700()of Division 3 ofthe Business and Professions Code)
_ p ATION —
SWIMMING POOL ELECTRIC
of
Smhmhelaexemptny applicantsubjects
703[.5by anyapplicantfar$permit xubjeeuthe ePPlicentmecivil penalty of
ppand she Permittheto civil
OUTLETS - SWITCHES - FIXTURES
moima
nal mom than five hundred dellors ($SW).
❑ I,mnwnendNcproperty,ormycmploy«swish wageaas abeirsolecompensation.
NEW RPSIDF.NTIAL ELECTR —SQ, FT.
STORIES
TYPE CONSTRUCTION
willdo the work, andthe awu
mrmis not inndedoroffmai forsale(Sm.]044, Business
and Pndesaion.a Code:'Do Con mmot's License Law docs not apply m an owner of
property whobuilJsor improves thereat, end wormers such weak himselforduough his
mwnempiuyms,providedshnl snchiniprovementsumnotintendulorrlfemdforialc., If,
OCC. GROUP
RE'S. UNIT'S
TOTAL:
however, the buildingor improvement is sold within one year ofcompletion, theowner-
Pride, will have the burden of pmsing that he did not build to improve fur purpose of
p ..
QTY! i PLUMBING PERMIT FEE
+,
auleY
❑ I, as ownerofahe n umexclusivel contracting with licensed eantractorsto
Pee Y� Y 6wi
ROOD LONE
APN
ransomer the (gee. Business and Pmfahmild Code:) Connector's
of not osma improves
Lawd«snm epplymawith
PERMIT ISSUANCE'
whoeUmom
.,cofactor )wM1nsedpemimproves Contractor's
for such proj«ewithacrnvacmr(e)Iicenud pursuer to We Comrecmr's
License Law.
License Law.
ALTER EA
( l
I FEE SUMMARY
❑ 1 am exempt under S«. , B & PC for this meson
BACK FLOW PROTECT. DEVICE
TSIDF.S
SANITARY Y N
RECEIPT.
Owner Date
DRAINS - BOOR, ROOF.AREA, GOND.
WORKMAN COMPENSATION DECLARATION
SCI100LTAX Y N
❑ I hctebyaffrm that l have a certificate ofconaem to self -insure, ora certificate of
Workers'Compensation insurance macerified copy thervemi 3800, Lab C.) which
RECEIPT.
FIXTURES -PER TRAP
PARK FEC Y N
covefsall e.,I, y
Yr1icY# _(f
GAS-G.SYSTEM-I INC40UTLETS
ECEI"
BUILDINGDIVISIONFEES
Co.,.!
GAS - EA. SYSTEM -OVER 4(EA)
PLANCHCCK FEE
❑ CmdieJmpyfaherebyfrraned.
GREASE-(INDUSTRI. WASTE INTERCEPTOR
GRADING FEE
❑ Cenifed copy is fled coli Ne city inspeeuondiviaion.
CERTIFICATE OF MFiMPTION FROM WORKERS'
GREASETRAP
SOILS FEF.
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 20l
ENERGY FEE
(This section need not he completed ifthe permit is for one hundred dollars 1$1 W)
ar less.)
WATER HEA TER W/VEN'I'/ELECI'R
I certify that in the paformmum of the work for which this permit is issued, Ishv11
our employ any .on in any manner so r to beivare aubj«t to the Work.-
PAID
Compensation Lawsof Colifmnia. Date
WA'TiRSYSTEM/IREATING
Date Receipt.
Applicant
NO NCE TO APPLICAWIf,of« making this Cenifrcateof Exemption, you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
berme mlijecuo the Worker., Compensation provisions of the Lith nr Code, you most
forthwith m ndy with such provisions or this permit shall be deemed revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that here is a construction lending agency fm Ne performance of
work for which this.mitis is issued (Sec. 3119'!, Civ. CJ
TOTAL:
ELECTRIC PRE
landaus Name
Lenders Address
Q'ry. MECHANICAL PERMIT FEE
PLUMBING FEE
I certify that I have read this application and state that the above information is
correct. lugrecm comply with ailcity and<ounay ordinances end sate laws reladngm
building construction, and hereby authonre representatives of this city to enter upon the
above-mentioned property for inspection purpoau.
PERMITISSUANCE
MECIIANICAL FT;E l'
ALTER OR ADD TO MECH.
CONSTRUCITON'1'AX
(We) agree to save, indemnify and keep harmless the Cit of Cu no against
liu"our judgments, costs and expenses which may in any way c eip City
AIR HANDLING UNIT (TO 10,000 CFM)
in co ouncethe guntin is permit. ,lJy�`
AIR HANDLING UNIT OVER IB,IXq CFM)
nature of Applicant/Con iscurn It pate
EXHAUST HOOD(WMUCD
PAID
HEATING UNI 'F(TO IW," BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Racipt#
HEATING UNIT (OVER I MEW H' TO)
TOTAL:
Will the applicant or future building rampant score ar bundle hvankma mursHal
as refused bythe Cuperam Municipal Cod, Chapter 9.12. and me Health and Safety
VENTILATION PAN (SINOLB RESIT)
Code, Salon 25532(a)R
El Yea ❑ No
ISS DATE
Will applicant orfuture M1uildingoccupunmueyuipmemmJrvices whichetnia
BOILER - COMP (3HP OR 100," BTU)
jA[JCE
�, 1�
BOILER -COMP (OVER IW,LUO B'Go)
huzurdoua air commoners as defined by the Bay Area Air Quality Management
Dislrictl
❑ Ya ❑ No
'JAN 18 1994
NEW RESIDENTIAL MECH.—SQ. FT.
1 have read the hmwdous materials requirements under Chapter 6.95 of the
California l lealth & Safety Code. Sections 23505.25533 and 25534. 1 radiational that
if the building does oat currently have a Roam. that it is my raaprnsibilfty to crafty the
CITY Ur L;UrtH I iNL)
ccupam 01 the mquiremmuls which matt be met prfar or issuance of a Cenifcate of
Occupancy.
ISSUED BY:
Owner or uulhorixN agent DateT
��
OFFICE