26836 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING-ELKL I RICA L PERMITNO,
APPLICATION/PERMIT PLUMBING-MECHANICAL, n �O O C
6
DIVISION BUILDING PR(3JECT IDEN'I'IFICA'FION BUILDING. 8 3
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMfITAL DATE
160 / —S gA r ✓U/\N—IV
WuM'IT4 (,� LOT, S
�. QWNIiRS#AMI!: - PHONE: COTRAMM.']5 NAME: N/C C•� CONTROL#(
AtCH1'BiCT/ENOINEER: LIC NO: ADDRESS: f/Lv ❑
CONTACT: PHONE: "
QTY. ` ELECTRIC PERMIT IWdE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE IPI ❑
LICENSED CON'TRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DESCRIPTION
I herebyaffirmtba[I am license)unJ<rprovixions of Chepmr9(commerem,with
(+100 Scene.7000)of Division 3 ofthe Businessand Professions Cale,and my license is in PANELS
&;-,E Trot Tonto send effect. ��
FZW License Class Lic.# UP T02W AMPS
m6a Date Comrsear 201.1000 AMPS
ZOyZ ARCHITECTS DECLARATION SQ. . FLOOR AREA S/SQ.FT,
OZ—C Iunderstand toserec
y,innsshall Ileud m public ords. OVER IOW AMT'S
N
W SIGNS ELECTRICAL
a
Licensed Professional
aj y.K a
OWNER-BUILDER Iadoamp,fr.the Contractors
SPECIAL CIRCUIT/MISC.
KOiO 1 hereby,n.(Se Lha,1 am excmptfrom the Convector's License Law for the
W 3 W y following mason.it (genion 7031.5.Business andprofessions
se.de io demolish.
Code:My city or<ounre TEA1P.MBI'FR OR 1s01.13INST.
�'�; whichitrasscolones n pemdt m c.aarvc6.lila,improve,demolish.or repair any tatem ni
Wm}� that hoits icensed Pursuant
requires provisions
Coat
Law
POWER DIiVICES
paj 5 p 0 that he is licensed pursuant,o the provisions of the Com 'cenx Law(Chapter
Kej 9(rotmn<ncing with Section 7")of Division 3ofthe siness an ssiens Cale) SWIMMING POOL ELECTRIC VALUATION
,2uo or that he is encmpuberefmmvnd,he bas is Tor#ruling es em tion.Anyvf OUTLF,TS-SWITCHES-PIX'NRES
�ZQ Smction]B315by any.pplicnm torn permit subjemst npaican acivird
hna
W ennm mom than Eve hundred dallara(SSW). NEW RESIDENTIAh ELECIR _SQ.FT.
EI {,aeo oftbepropmy,ormycmpl I.'with ageyast can ami n, STORIES TYPECONS'FRUCTION
p, will Bothework,and the machine is intends sort red fn .] ,1 as, ss
and Professions Code:The Contra s License 1 does Fly��ttQQ an�ow of
Foolery who builds or improves theram,.ndwhaI ssuchw r s[lflgihto his OCC.GROUP RES.UNITS
own employees provided Thal is
am net'. nor ory[fe�Sl fora .IL
however,the building orimpm.emem is sold wit noneyca fco ,the wner- TOTAL:
builder will have the burden of powinglhat he dno improve rpu uof
sale.).
❑ L.sownen+I'thn"perty,em exduxivc onvn t g i millennia rorsm QTY. PLUMBING PERMIT FEE /5 FLOODZONE APN
construct the project(Sec.704,L Business and ions Calre)The Con mr's PERMIT ISSUANCE.
License um Lawdonapply tont ownerarpropbat eny whoimIF vuthe o,anJ
whocnmmns fur such projects with.commoun(s)licensed,arta nvacmrs
License Law. ALTER.DRAIN&VENT-WATER(RA) FEE SUMMARY
❑ 1 am a Calla under Sec. ,B&P C ler this rouon BACK FLOW PROTECT.DEVICE 9'.IDE FEES
SANITARY YN
Owner Data RECEIPT#
URAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
o 1hereby official
ensat that 1have a ora nemeie corson pythe xel(Sec.rc,motab C.)which
of RECEIPT,
orkery Compensn,iun Insurance uracedilietl copy tbercnl'(Sec.3gW,l.ab CJ which FIX'NRES-PER TRAP �3 ,ARK PCE YN
Avers all employee'.under this Permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT'#
'Dopey# BUILDING DIVISION RES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cmifiedeopy is hereby famished.
❑ Certified copy is filed with the city inspw,ion division. GREASEIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORRIES' GRI?ASETRAP SOILS RE
COMPENSATION INSURANCE
(This section need not be completed tribe permit is for one hundred dollars(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY RI?
nr less)
I codify that undue peif...of the mark for whichlhis permit is issued.I shall WATER HEATER W/VENT/ELECTR
Cor employ any penun�3Secnyne spl{ject m the Workers Agip
Com on,le,on L�, B Spm Dae U[ 9`I WATER SYSTCM(1'REATINO Date Receipt at
O z Applicum IG
z 0 NOTICETO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDF.N'TIAL PI.MB. SQ,FE TOTAL:
rV] become subject to the Workers Compensation provisions of the labor Code,you must
aforthwith comply with such provisions ortbis permit shol l be deemed mvoked. BUILDING FBF
W (] CONSTRUCTION LENDING AGENCY SEISMIC FEE
5 1 hereby.ffirm that(here is a construction lending.,me,fur the performance of
U O the work for which this permit is issuM(Sec.3007,Civ.C.) TOTAL: ( ELECTRIC FEE:
Lender's Nmne Eedify that PLUMBING FEE FYI^ Lenders ply that QTY. MECHANICAL PERMIT PER
U 1. t 1 have Tsui this application and smm that the shove information is
science.legrcc to comply with all city add countycountyordinances and nate laws
rcle[ingmPERMIT ISSUANCE. MECHANICAL FEE
h" building construetion,and hereby radiation representatives of Nis city to enter upon the CONSTRUCTION TAX
U Z .have-racch...dpropmy far inspection purposes. ALTERORADDTOMECH.
(We)ag e m save,indemnify and keep humlus the City of Cupenino xgdns[
liahili[ics,j tent,conisd expenses which may in my way accrue against said City AIR HANDLING UNIT(TO 10.000CFM) r/Q
in cense a re the granlinp oL011sy omit.
/.err,/, \ AIR HANDLING UNIT(OVER 10,000 CFM)
Sig m lie /Comram r Dov EXHAUST HOOD(W/DUCI) Hyl
PAID O I
AZARDOUS MATERIALS DISCLOSURE BEATING UNIT(10110,000 BTI) [),m Receipt#
Will ion...he..,or future building occupant Brom or handle hazardous material
as defined by the Cupertino Municipal Calc,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTI) TOTAL:
Cade,Semi 25532(x)?
CIY. El No ILVENTATION FAN(SINGLE RESIDE
❑
,•! "� BOILER-COMP(3HP OR 100,00)BTU) �ISJSUAyCE'tlV/DAT1?
k'
y Will the upplicanmr future buiidingoecupan,meequipmentordevlceswhichemit
Pzam
nrdous air comntinmts as defined by,he Bay Arca Air Quality Management BOILER-COMP(OVER 10t B'I'U)
ander? C3 - 5 1994
❑Yes Na NEW RESIDENTIAL MECH.—SQ,FT, AUG
V, 1 have mad,he hazardous materials requic mems under Chance 6.95 of the
Cattleman Health&Safety Code,Sections 25505,25533 and 25534. 1anderswnd that CII Y Vr vvrCn UltlV
if the building does no,normally have a mmm
m �,that it is my responsibility notify the
rccupnm of the ant iremems which mus[he met prior ,issuance of n Cenifcate of
Occupancy.
x
Owner or amhmiud agent Date TOTAL: ISSUED BY: �!
OFFICE