26811 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-'USE BALL POINT PEN ONLY
CITY OF CUPERTINO 11.111"pily.11"PICIEICAL PERMIT No.
APPLICATION/PERMIT PLUMBING-MECHANICAL. C O'I
BUILDING DIVISION BUILDING PROJECL'LDENI IP'ICATION o 0 1
BUILDING ADD�R]ESSS:s SANITARY NO, APPLICATION SUBMITTAL.DATE
UNITp OT# 7�q �
OWN' SNAMIi: PHONE: CONE OR'S NAME: LIC NO: L
/1 U.�7r _ S N C coNTRo a
ARCIUMCTpINGINHER: LIC NO: A KEESSS: El/S/CIA i.
CONTACT: PHONE: ppa�dy i F 8 A ` ` tr' =i BUILDING PERMIT INFO
FEF..
BLDG ELECT' PLUMB ME CH
qN .z7a 3 PERMIT ISSUANCE
LI CIIIOSEDCONTRAerpmviionsof apterN APPLIANCES-RESIDENTIAL HOLY
vsd Dp
p00 Thereby effimnhatl min 3 ofth Business and
Professions
Coer and mmecense with ��.' yea
0:W Seniorce it of affect. on 3 of the Business and Professions Code,and my license is In PANELS �`t"•`'
FF<U fall License
Claseffecs. UPT0200AMPS
QFZty Licenm Class Lica I S
N<ti Data Cormatemr 201-1000 AMPSzi
a•
z0 ezARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
0z_G 1 understand my plans shall be used as public words.
C Y t alCCCC SIGNS ELECTRICAL Licensed Professiaml
C d'Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
•�•add'06F 1 herchy M.
but I am exempt from the Contractor's License Luw for the
Y134w following mason.(Section 7031.5,Business and Professions Code:Anycity orcounty TEMP.METER OR POLE INST.
F(LOQ, which requires a permit to construct,alter,improve,demolish,or repair any structure
}$ im mitlssnamce.aEo requires theapplicunt for such permifto File a signed statement POWER DEVICES
�p 9(comisncing withSuannothepmvisinnsof the CeBusinss License Professions
9fcommencing with Senion000(O of Division3ofthe Business end Prafessiom Code) SWIMMING POOL ELECTRIC V ATION
0.W: or that he is exemptherefrom and the basis for the alleged t My ger pion.An lotion of OUTLETS-SWITCHES-FIXTURES
Section 7031.5 by any applicant for a Permit subjects the applicant m o civil Family of
not mare than five hundred dollars($500). NEW RESIDENTIALELECTR _SQ.
K p ElI,asowneroftheproperty,ormyempdoyas with wagesustheirmlecompensatme, FT.
RIIS 'TYPE.CONSTRUCTION
y will Jr the work.and the structure is not intended moffmad forsale(SecJ04q Business
had Professions Cade:The Carnivores Liceme Law does not apply to an owner of
pmpeny who builds or improves thereon,and who does such work himsedfor through his
owaemployew.pmvided that each improvements.not itilmdedoroffemd torsade.If, I C.vR P RES.UNITS
however.the buildingor improvement is sold within oma yarofcompdceon,the owner- T
Its I
builder will have the harden of proving that he did not build or improve for purpose of
$.y
s❑)1,mownerofthepmpeay.amexclusivelycontrectingwithliansW.nwetorsm QTY'.3f,' r -PLUMBING PERMIT FE FLOOD ZONE APN
concoct the project(Sec.7044,Business and Professions Code:)The Con Tactors
Liccmel.aw Atoms no apply him mvie f pmpeny who mi Ids or improves thereon,and PERM IT ISSUANCE
who contracts for such Projects with a comracmgs)licensed purmanto the Contracmri pL'IER-DRAIN&VENT-WATER(EA)License Law. FEE SUMMARY
❑ I am excmpl ander Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE OUTSIDE ITHS
SANITARY YN
Owner Date RECEIPT#
covers
ROOF,AREA,COND.
,W./ WORKMAN COMPENSATION DECLARATION SCIIOOLTA% YN
W cm'Co Compensation
shall Insurance
ora
copy them f(Smure,of as C.))am of RECEIPT'#
FlXTURFS-PER TRAP
rkers'Cnmpensminn lnsumnce turacmified copy thereaf(Sa.38W,Lab CJ which PARK RL' YN
all employees under this permit. GAS-EA.SYSTEM.I INC.4 OUTLET RF.CEIPI'a
Policy p BUILDING DIVISION FEES
pny
Com aOC��-- _A� 1
GAS-F,A.SYSTEM-OVER4(EA) PLANCIILCK F[?C
El out copy is hereby famished.
CmifieJ copy is filed with the city inspection division. GREASFJINDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASF.TRAP SOILS FEE
COMPENSATION INSURANCE
(This maintained not be completed ifthe permit is fortune hundred dollars SUX) SEWER-SANITARY-STORM EA.2111 ENERGY ME
or less.)
I codify that in the performance of Ne work for which this permit is issued,)thing WATER HEAT ER W/VII/LLECTR
not employ any person in nay manner so as mo(mm c ;
; a the Workers PAID
Cnmpensatinn fowl of re. Data WATER SYS]'EM/1'REATING Dme Recciptp
,Z, Applicant—yl( _�_ � I x
z7�-r NOTICE TOA (CANT:IL after mkmg ethis Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.IT. TOTAL:
F' .�.. become subject to the Workers Compensation provisions of the Ltian Code,you must
, forthwith comply with such provisions or this permit shall be domed revoked. BUILDING FEE.
W O CONSTRUCTION LENDING AGENCY SEISMIC FEE
^� I hereby affirm that hucti
hem is a conson lending agency for the perm
fnmaa nof
the work for which this permit is issued(Sec.3(1 Civ.CJ TOTAL: ELECTRIC FEE
Lender's Name
V.
- t PLUMBING FEE
Lenders Addmsa QTY. � "MECHANICAL PERMIT' FEE.
U I codify mbar 1 have read this application and ante that the above information is
""act. I agree to comply with nit city and county ordinances and state laws relating toPERMITISSUANCP. MECHAN ICAL FEE
building construction,had hereby authorize representati.m ofthis city former upon Ne CONSTRUCTION TAX
V above-mentioned proprp
property far inspection purposes. ALTER OR ADD TO MECH.
(We)ngfa m mvo,indemnify and keep harmless the City of Cupertino against
Iiabilitim,judgmems,costs and expenses which may in any way acemeageinst said City AIR HANDLING UNIT(TO 10,000 CIrM)
ncommutation of the gran
� ting of Nis PPec�w t.
AIR HANDLING UNIT(OVER 10,000 CPM)
Signature of Applicata/Contmetor Da EXHAUST HOOD(W/DUCq PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,BEB BTU) Dam Receipt#
Will the applicant or future building occupant store or handle hazardous crateriad
as defined by the Cupertino Municipal Code,Chapter 9.12,end the Ilcahh and Safety HEA'T'ING UNIT(OVER 100,000 BTU) OT L:
Code,Sects❑Yrs32(a)P ❑No VP-NTILATION FAN(SINGLE RFSID)
Will thc applicenmmb
rforcuildinccu
gapm
euseequipmenmrdeviaswhichemit BOILER-COMP(BIT OR 100,00)BI U) ISSUAN¢ jEDA•TE 6/
. hazardous air madaminanss as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100,000 BTU) �u/
District? ❑Yes ❑No NEW RESIDENTIAL MECH. SQ.IT. �S 9 1994
I have mad the hazardous materials requirements under Chapter 6.95 of the t/ Uj- rr
Califnmio Health&Safety Code.Sections 25505,25533 and 25534. 1 understood that
if the building does net currently have a mneme.Nat it is my responsibility m notify the
capons of rhe rcyuircmen6 which must he met prior In issuance of a Cenif<ate of
Occupancy.
Owneror smhnfized agent D:np TOTAL: ISSUED BY:
OFFICE