26022APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO B I l: -"..ECR A
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING PROJEC'IADENI'IFICATION
PERMIT NO.
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L v L L
BUILDING ADDRESS
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V3 q4 4a UNIT# LOT#
SANITARY
SANITARY NO.
APPLICATION SUBMITTAL DATE
O NERS NAME: PIfONG:
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CONTRACTOR'S NAM ^ LIC NO:
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NIC
❑
CON'IROLp
ARCHITECT/ENGI EER: LICNO:
ADDRESS
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2-&74 "eg �✓ %S/2/"
CONTACT: PHONE:
QTY, GLECTRIC PERMIT PF.E
HUII,UING PERMIT INPO
ELECT PLUMB MECH
PERM[f ISSUANCE
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affin i dito l am licensed underprovixianx of Chep¢r9 (commeneingwith
Section 7") of Division 3 of the Business am4 Professions Code, and my license is in
full toand effe< Z'
Liceau� Lic. g
APPLIANCES - RESIDENTIAL.JOB
PANELS
UP TO 200 AMPS
DESCRIPI'10
n
Date Conbanor
201 - 1000 AMPS
ARCIIITECI'S DFC ARATIQI
I understand my plana sM1all be used as public records
OVER 1000 AMPS
SQ.'T ARE
p p a- g� J p S
,tl./■ a\VY
5/SQ. Ff.
SIGNS ELECTRICAL
O/,O 1pL fL.�
Licensed Professinmal
OWNER -BUILDER DCCContra ON
SPECIALSPECIALCIRCUIT/M15C. I
p UTE R
I hereby affirm Nam
al I exempt from the Contractor's la
or's License w for the
TEMP. METERORPoLF.INST.
following brown. (Section ions Code: Any city or county
_ t _
which requires t, ithessandct..de
contract,
which permit re mnswa, altars improve, demolish, ar repair any swnure
�JIIT/1 JVI
issuance, thefile ase statement
slcensedpursuant
POWER DEVICES
.2)o-
that heor
Co tramiuo
nt to the pr provisiont nor s
that m is licensed pursuant m the provisions of the Contractor's License Lew (Chapter
La
J(commencin with Section ]f100)mfDivisionJmf Oe Business and Profeainm Code)
(commencing )
or that he is exempt herefrom and the basis for the alleged exemption. Any violation of
Smctloo 7031.5 by any upplicumfor a pxmu(,ahjml, t he nppliean In u 6,i l penally of
SWIMMING POOL ELECTRIC
VALUATION
�7 ^
OUI'LI?TS- SWITCHCS- FIXTURES
outrn
I mothan rive hundred dollars 6500). ❑ 1, asowneroftbepropeny,ormyemplo mswith wages ustheirsolecompens lion,
NEW RISIDENTIALELGCTR _SQ.PT.
STORIES
TYPECONSTRUCTION
will do the work, and the structure is not intended or offered for We (Sec. 7044. Business
and Rnfessions Cele: The Contractors License Law does not apply to a owner of
property whobuildsor improves lhetern,and whodoes such work hlmselforthrough his
own employees, providedthan such improvements arc not boadedoroffered foraals. If.
OCC. GROUP
RES. UNHS
TOTAL:
however, the building or improvement is sold within oneyear of completion, the owner -
builder will have the burden of proving that he out not build or improve for purpose of
QrTY: PLUMBING PERMIT � PEE
❑ I,aownerofthe property, amexclusively contracting with licensed contractors to
FLOOD ZONE
APN
construct the project (Sec. 7044, Business and Professions Code:) The Contractors
License Law does not apply loan ownerofpmpeny who builds or imparmsthimm,and
PERMITISSUANCE
wbeconrzns fimsuch projects withaco micir(s) licensedpursuant lathe Committers
License Law.
ALTER - DRAIN & VENT- WATER (FA)
FTE SUMMARY
❑I am exempt under Sec. . B & P C fm this reason
BACK FLOW PROTECT'. DEVICE?
UTY D
Owner Date
DRAINS - FLOOR, ROOF, ARCA, COND.
SANITARY N
RF:CI IFI'M
WORKMAN COMPENSATION DECLARATION
❑ Iherehy affirm lhatlhuveucenificum ofamxem to self -insure, or ucenifcum of
Wnrkeas'Cnmpensntion lnsumnce meeertified copy thereof (Sec.38W, hob CJ which
SCHOOLIAX Y N
RECEIPI'p
nXTUNI?S -PF.R TRAP
PARK FEE Y N
GAg - EA. SYSTEM -1 INC. 40UTLE1'g
coven all employee's under his pe�rlit
PolicyM / 0.
RHC[i1P1' M
BUILDING DIVISION FEES
C�^Y
Certified copy is hereby famished.
GAS - F.A. SYSTEM -OVER 4 (EA)
PLANCHECK ME
GRFASEBNDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Certified copy is filed with the city inspection division.
CERTIFICATC OF EXEMPTION FROM WORKERS'
GRFASF,TRAP
SOILS PCI:
COMPENSATION INSURANCE
SEWER -SANITARY- STORM EA, 211017.
ENERGY FEE
(This section need not he completed Blue pemlil is for onehundred dollars ($10(d
less.)
WATER 11GTER W/VENT/ELECfR
I cmifythatmile, performance m die work for which has permit is iasuW, l shall
not employ any person in any member so as to become subject to the Worked
PAID
Compensation f.awaof Calilomis. Date
Applicant
WATER SYSfEMITREATING
Date Receipt p
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
NTIW RESIDENTIAL PCMB. SQ. FT.
TOTAL:
become subject the Wmium's Compensation provisions of the Labor Code, you most
louhwith comply withact, provisions or this Perosis shut] be deemed revoked.
BUILDING FEE
SEISMIC FEE 1
CONSTRUCTION LENDING AGENCY
1 hereby affirm that them is a construction lending agency for the performance of
the work for which this Permit is issued (Sec. 3097, Civ. CJ
Lenders Name
TOTAL:
ELECTRIC ICE
Leader's Address
QTY. MECHANICAL PERMIT FTE
PLUMBING FEE
1 malty that 1 have read this application and state that the above information is
comoct. I agree to comply with all city and county ordinances and state laws relining to
PERMIT' ISSUANCE
MECHANICAL IEP.
holding construction, nnJ herchy authonze representatives of this city to enter upon the
above-mentioned progeny for inspection pur,xims.
AIA IzR OR ADD TO MECII.
CONSTRUCf10N TAX
(We) agree m save, indemnify and keep Iarmless the City of Cupertino against
liabilities,judgments, costs and expenses which my in any way accrue against aid City
AIR I JANGLING UNIT (T016.000 CFM)
to consequence of the grinning of this permit.
AIR HANDLING UNIT (OVER 10.010 CFM)
Signature of Applicant/Commuter Date
EXHAUST f[GOLD (W/DUCT1
PAID
HCATING UNIT (TO IW,000 B' I' U)
I IAZARDOUS MATERIALS DISCLOSURE
Date Receipt#
Will the applicant or future building accupent store or handle hazardous material
as defined by the Chper ian Mmulped Code, Chapter 9.12. and the Health and Safety
HEATING UNIT (OVER 100,00D BTU)
TA L.
Grde, Section 25532(g?
❑ Yes ❑ No
r.
VENTILAI ]ON FAN (SINGLE RISID)
building or which nt
Will the acarbomoion
BOILER - COMP DHP OR I W." BTU)
ISSUANCE DATE
p�
BOILER- COMP (OVER 100,000 BTU)
by the Bay Amequip
in QualiManagemees
hamrdous air comaminunb a defined by the Bey Area Air Quality Management
ty
District? '
Y•' I ID
I ❑ Ycs ❑ No
NEW NCSIDENTIAL MECII. SQ. FT.
1 have read the hazardous materials requirements der Chapter 6.95 of the
Call fomI.H th& Safety CMe,Scetions 25505.255) 25534. I understand that
V/iY 1994
if the h it g does not he, it i responsibility to notify the
scup. f the requirements whi ust a P 0 issuanceof Aficat f
Occu Y.
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LfJhr
hNl
ISSUED BY:
or mJ t te
TOTAL:
v v OFFICE