26141 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO "'Nom- LAU rRJCAL PERMI'NO. 2 6141
APPLICATION/PERMIT PLUMBING-.MECHANICAL
BUILDING DIVISION BUILDING PROJECT'IIIEN'1'IF'ICA'1'PON
ILDINGGA//DDDR�REES�SS. SANOARYNO. APPPPLICA HON SUBMITTAL DATE
C. kc) r`e UNIT# LOT
OWNERS NAME: NF—: /RNME: LIC N
� Lt��'JL O: / CONTROL
TROL#� N/c 1• 1
ARCIII'I'IiC'I'IIiNGINH, �✓ LIC Np:_ _ RESw
CONTAU': PHONE:
.''°'Y I BUILDING PERMIT INFO -
1 ` - �p QTY,; o.; ELECTRIC'PERMIT FEE
�LJP� "'F`J" `' � • LDG F�L�ECf/ PLUM MF.CH
• '- �+��++ PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
py.Z I hereby affirm Nut l am licensed underpmvisionsofChapier9(commeneingwim
PBOO Section 2011)of Division Softhe Business and professions Code,and on,license is in PANELS
yl4F full force and effect —^ �I�
FZtU Data
Lic.N /LL UP T02W AMPS pop. n61 ,
y Q y Dme Convector 201-1000 AMPS pop $J V[/
zoo, ARCHITECTS DECLARATION OVER 1000 AMPS ^SQ.Pr.Fl. 'A $/SQ.FT.
O Z—p 1 understand my plans shell be used u public seco(ds.
SIGNS ELECTRICAL VV1
aLicensed Professional
OWNER-Bnamn from
mEC Criana ON SPECIAL CIRCUIT/MISC.
O O I hereby n.(Se thus 1 son exempt from the Cocoons Co License law for the -
py
following rcawn.(Secdomconstru Business and Professions Code:Any city orcounry TEMP.METER OR POLE INST.
which rcyuircs o permit to construct,ehcq impmvq demolish,or repair any xlmcwm
Y� farm its issuance.also requires the applicamfar such .I,to filed signed statement POWER DEVICES
W ce O p that he is licensed ponuaml a the Provisions of the Convecui s List.Law(Chapter
a K 9(commencing with Section 900)of Division 3 of the Business and Professions Code SWIMMING POOL ELECTRIC
opy (° ewi ) VALUATION
µ)_y
a,that be7031. by
therefrom and the basisfonhects alleged
application.Any violation of UTLETS-SWITCHES- _TG O��
Y Semion911Jl Shy anyapplicuntfor epetmit subjects the applicant loacivilpenahyof FIXTURES `• ^^w..///
C not more than five hundred dollars($500).
Wim ❑ 1.asownerofthepro any,ormyanployeeswithwagesmtheirwlecompettsanon, NEW RESIDENTIAL ELEGTR _SQ.Fr. STORI. TYPE CONSTRUCTION
L3-, will dothe work,and the structureisnot intended°roffered forsale(See.J1144,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
property whohuildsor improves thereon,and whodoessuch work himselforthroughtis OCC.GROUP RES.UNITS
wnemr.the building
uiimprovement
ve improvementsarenot intendedmoffered forsole.IL
however.thethe
brimpmvementi that he withinne build of completion,theowaspausomeof T �•
builder will have rhe burd[n of proving that he did not build m improve for puryow°(
ale.).
❑ Lau nwnerofthepmpeny,umexcluaivelycomracting wiN licenxdconvamom to QTY. PLUMBING PERMIT FEE ------F100D ZONE APN
construct the pmjem(Sec.9044,Business and Pofessions Coda:)The Commetor's
License Law does not apply loan ownerofpmpeny whobtildsorimprovesthercon,end PERMIT ISSUANCE
whocomLaw.fisr such prnjatswiNacontmctor(s)licensed punuanuo Ne Convecmr's ALTER fA
License law. (' ) FF.F:SUMMARY
❑ I am exempt under Sec. B&P C for this mssan BACK FLOW PROTECT.DEVICE OUTSIDE 1717
SANITARY Y N
Owner Dat° DRAINS-FLOOR,ROOF,AREA,COND. RECRII'l'#
I WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y
❑ Iherebyaffirm that l have a certi0care ofconsent to self-insure,or a cenificate of RECEIPTN
_ Wmkers'C°mpensmion lmumncemaanified copy theomf(Sm.3901%Lob C.)which FIXTURES-PF.R'TRAP PARK FEE Y N
ars all employee's under this permifGAS-EA.SYSTEM-IINC.4OU`MEfS RECF.1 N
Policy# B LD DIV IONFEES
Company GAS-EA.SYSI HNIOVER 4(G) PLANCHECK
[I12 d
Ceniliedeopyisbcoehyfrmished.
❑ Certified copy is filed with the city inspection division. PREASEANDUSTRI,WASTE INTIRCEPTOR GRADING / �f _N
CERTIFICATE.OF EXEMPTION FROM WORKERS' SOl {—
COMPENSATION INSURANCE RF STRAP L_ ILS FE —�
(This sectionnaJ nut hecompleted if the permit is for one hundreddollum(51001 F.W ITARYF$TG.M/iA]2(IflPT.T ENERGY
r.r less)
I certify lhalinthe perfonnanr<ohhe work for which thispemtit is issuW,lshell ATER HEATER W/VENTfELFCTR
not employ any person in arty mann u to become subject to the Wmden' PAID
z Compemationlawsof Celifomia De¢ so A'fER > Data Recelp N
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLhIB. SQ.FT. TO'AL:
to become sAjocuothe Workers Compensationpm,sr.nsof,ha labor Code,you..at
FFFa"' ; forthwith comply with such provisions or this permitslWl be dammer revoked. BUILDING FEB If 1a
Q CONSTRUCTION LENDING AGENCY SEISMICITF
V z I hereby uffinn that is a construction lending agency for the performance of
the work for which this permit is issued(See,3097.Civ.C.) T ELECTRIC FIR' _�
fY Lenders Name �.
I-) Landers Add., QTY. MECHANICAL PERMIT FEE PLUMBING ITE
U Icertify that 1 have reed this applicntimn end store tM1m Ne above infomrntion is
connect. I non,to comply with all city mW county mdinances andnate laws rclatingto PERMITISSUANCI3 MECHANICAL FEE 43��
f^ building constmction,and hereby authorize sepsesenmtives of this city to enter months
U 7 uve-mentioned pmpeny for inspection purposes. ALTERORADDTOMECH. CONSTRUCTION TAX
M
F7 (We)agree m save,indemnify and keep hurmless the City of Cupertino against
liahilitics,judgments,vests wJ expenses which may in arty way acmueegairetmid City AIR HANDLING UNIT(TO 10,00 CFM)
to comon,ane tbe,rabongofthispesmil.
/ _ AIR HANDLING UNIT(OVER 10,00 CFM)
ignxmre of Applicam/Contractor Date EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MA :RDISCLOSURE HFATING UNIT(TO 10,000 BTU) Date ReceiptN
Will the applicant or future building occupant store or handle haamdous material HEATING UNIT(OVER FOR"11TU) T
m defined by the Cupertino Municipal Code.Chapter 9.12,and the health and Safety
Code,Section 25532(4)? VENTILATION FAN(SINGLE.RESIDI
❑Yes
El
Will theapplicant m iumnalooldin q pm BOILER-COMP Olin OR 10,0(X1 BTU)
ISSUANCE:DATE
2goccupe Bay of it Quality Manage ent MAR 9 0 r hazardous air contaminants as defined by the Bay Arm Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have read the huaurdous materials requlr anent under Chapter 6.95 of the C11 Y Ur VUrrhI INU
Califomin Health&Safety Code,Sections 25505,25533 and 25534. I understand that
if the building des nm cmrently have a omam,that it is my responsibility m notify the
nem,am of the requirements which most be met prim to issuance of a Certificate of
Occupancy.
Owner or tmthmi zed agent Data T ISSUED BY:
OFFICE