26097 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO Rl7ILIHNT.-RT.FZTN. PF:HMI'TNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 26097
' IlUi1,U1HG IBOJhCT IUKN'fIFICA'1'ION
BUILDING ADDRESS: l�.�- �p�.�) (/.1- SANITARY NO. APPLICATION SUBMITTAL DATE.
6 + spwl � URTI'X LOT V
OWNF. SNA PHONE: LIC NO:
N/C ���```'''��� ♦CONTROhIrp1
\RCHHEC/ENGINEFR: LIC NO: ADDRE4S: _ ❑ /l �� [tel+
CONTACT: PHONE: QFE8
k z. ' BUILDING PERMIT INFO
�
TYt :w k r ELECTRIC PERMIT
'
ELECT' PLUMB MHCH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
aci I hereby affirm that lnm licensedurderprovisions of Chacom
pter9( mencing with JOB DESCRIPTION
�00 Section 70007 of Division 3m`the Business and Professions Code,and my license is in PANELS
<z full force License
Clad effect. UPT0200AMPS
QZ License CWss Lu.
,o y Date Convector 201-1000 AMPS
ZONnz' ARCHITECT'S DCCLARATION OVER 1000 AMPS Q.ET.ILGO R AR A $/SQ.FT.
O Z^qqqq I understand my plans shall be used as public records.
�x SIGNS ELECTRIC
Q
Licensed Professional
Epd OWNER-escape it DECLARATION SPECIAL CIRCU IS . ^ _w
30riU 1 hereby effimh that I am exempt from the CanwcmrS Liana Law for the {,XGA`J lc' i(`
rt�'�+LLo, following remain.(Section 7031.5,Business W Professions Code:Any city or county TFF6IP.M OR INST. ` 1"
O; which rcquiree a permit m<onswet.eller,improve,Jemelish,or repair any swcmm
}� prior m its issuance,also requires the applicant forsuch amnitto file a signed sutement POWER DE CE
CC) that he Is licensed pursuant to the provisions of the Convaemrs License Law(Chapter
a1 y 9(commencin with Section 7"of Division 3 of the Business and Profnsimns Cade SWIMMING POOL ELECTRIC
k0{y (commencing ) I VALUATION
t)� Smithar 7031.5 by tNnefirmnapplicnt f the basis subjects
to civil
of ^ �a�1 y\
�Z< no,fr .in. veanyapplicantforapermit subjects th<apPlicvhuoa<ivil petWryof OVTI.h'fS-SWITCHES-FIXTURES ` [I— a
x not more Than five hundred dollars($500), NEW RESIDENTIAL ELWM S .fT.
❑00 ❑ Lnsaw work,
or ofered Burhei(sole cote.Brusi on, Q STDHIES TYPE CONS]RUCTION
y3°0 will do lesions and the he Conttructure actor License offered does not appins y to an Business
and Professions Code:The Commodore License Taw Joca not apply to an owner of
own cri whoes,promimprovuthereon,andwhodoessuch wart Nmselfor through his
howemployees,p building
or Improvement
ycarotdmpletiod the owner- OCC.GROUP MRS.UNITS
however,the building nr improvement is hold within one year nr improve
f r the owner- OT
builder mil have the burden of proving that he JiJ not buil)or improve for purpose of
a❑ale.)Lvnwnerofthepmpeny.a me lusivelyconimciingwiNli.dcanwemrsm QP+YF '~ ' PLUMBING PERMIT FEE F'LOODZONE APN
conswct the project(See.7144,Business and Professions Corl The Commerce.
License lawAcesnot applyman ownerafproperrywhobvilds orimprnves thereon,and PERMITISSUANCE
whoennmu:lsfmsuehpoluele withucon0odogs)licensed pursuantJmhe Contmetors PETER-DRAIN&VENT-WATER(FA)
License Law. FEE SUMMARY
❑ I arrexempt under Sec. .B&PC for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEF.
SANITARY YN
Owner Data RFC'EI"If
WORKMAN COMPENSATION DECfARAT10N '01AINS-FLOOR,ROOF,AREA,COND. SCHOOLTAX Y
❑ Iherebyaffirm Wml Insurance
of aceamofcopythmof(Srsure,0r acertificm FTX'USES.PER TRAP RCCI?I TN +
Wmken'Compewetian lnsurnnce ar ecenilied copy thereof(Sec.3g00,Lab is h PARK FECY N
n all employee's under Nis permit. GAS CA.SYSTEM-I INC.40V1'LFTS "Ing
Poli,# 1 G VI ION FEES
Company GAS EA.SYSTEM-OVCR4(EA) PLANCHF.
❑ Cenifieneopyis hmebyfumished.
❑ Cedilied<opy is filed with Ne city' sWedion division R SFVINDUSTRL WASTEINTERCEPTOR GRA E
CERTIFICATE OF FF%E PITON OR SFTRAP S LS FE ��
COMPENSAT NIN rfai
(Thi..+sarinn meet not hecamplltcd fthe - or dr�Jo s( 100) S -SANITARY-STORM EA.2001T. ENERGY FEE
m Rss.)
lemify thatin The performance oft a workf hich Nis is issued,I shall WATER HEATER W/VF.NT/CLECRR
nm employ any person in any(donne w as m oma su)ret to the We PAID
Compenmtion laws of Celifemia. no WATER SYSTEMITREATING Dale Rec' tp
Q OApplicant
NOTICE.TO APPLICANT.If,afro(me ing this Certificate of Exempti au should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
.�., become subject m the Workers Coope ation provisions of Lab nddyou..at
Fes" , foMwith comply with each provisiow phis permit shall he Wrtvoked. BUILDING FEE
W (� CONSTRUCT LENDING CY SEISMIC FEE
hYj Ihcmbyaff thanheroisacom omml I, Cary far the parfennsnce of O I IiLECTR1C FIiC
U O the work for which this permit is Issued( cc. 7,Civ.C.) l
Lender's Name
FU Lender's Address QTY..a{ - MECHANICAL PERMIT FEE
PLUMBING FEIi
V 1 ar,ify that I have rtad this application and nam Nm the.hove mfoff.ton is C r'a, '
correct.l agree to comply with all city and county^rdinances and sum laws relating to PERMIT ISSUANCE
MECHANICAL FEE
�+ building da.smunimn,and hereby auNorim mpresenudvee ofthie city tocmer apo^the CONSTRUCTION TAX
V shove-mentioned proper, I'or ins action purposes. ALTERORADDT'OMECII.
(We q the City of Cupcnino against
liabil" s no he andeapens .yin anyw einst said Ciry AIR HANDLING UNIT('1'010,000 CFM)
in nceo t e it.
AIR HANDLING UNIT(OVER 10,000 CFM)
1 Signemm Dam EXBAUSTHOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000 BTU) Dun Receiptp
Will the The Cuamnrfurorebuildingoccupanterreer handle Health. materiel
as deli red by the Cupertino Municipal Code,Chapter 9.12,and Ne Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
I Code,Scclion 25532(.)?
❑Yes ❑No VENTILATION PAN(SINGER RfiSID)
ISSUANCE DATE
Will theapplinntorfuwrcbuildingadupantuseequipmemordevime whichemit
BOILER-COMP DHP OR 100,000 BTU)
vnMeas air carNminanb.defined by the Bay A.Air Quality Management BOILER-COMP(OVER 100,000 BTU)
strict? ❑ PAID
Yes El NEW RESIDENTIAL MCCII. SQ.FT. '
I have read the hmamdous materials requirements under Chapter 6.95 of the MAy d 9198
California flealth&Safety Code,Scedi...25505,25533 end 25534. I uademenit hhet
if tae building does not emon ly have a lung.that it is my responsibility m eutify the
aerupam alu.require nen..which must he amt prior to i.euance of a Cedifludo of tt
Occupancy. IIY U1- t,urr .f
Owner or amhoriud agent Dme OT L: l ISSUED BY:
OFFICE