26796APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - LLI1C I RICAL
APPLICATION/PERMIT PLUMBING-MECHANICAL.26796
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
PERMITNO.
BUILDING ADORES.SANITARY
NO.
APPLICA'HON SUBMITTAL DAIF,
S( (.-LIIN1Tk LOT II
OWNERS lid \
'ONTRACI'OR'S NAMIi:
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A crop— S I y
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Nil
❑
^ �CONNaROL N
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RCHITECTIENGINEER: LIC NIT
DDRESS:
M6W_% ERE �5A
CONTACT: PHONE:
QTY. 171-ECTRIC PERMIT FEB
BUILDING IafiRM1T' INFO
HE DO ELECT PI.0 MECH
A-
!�1 ` ,arlq
1/V
PERMIT ISSUANCE nn
q rt 2.
LICENSED CONTRACTOR'S DIiCLARATION
I hereby firm that l am licensed under n fCha mril (commencing
Yv provisio ao p (o gwith
pppL1ANCESRESIDENTIAL
JOB DESCNIYI'ION
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FZ�
Ln <y
Fy7ARCHI'1
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Scotian90110).(Divisor 30fthe Bteiness.nd Professions Codgand my license is in
full farce and effect.
License Class Lie. N
Dale Contractor
PANELS
UP TO 20)AMPS
201-IIXIU AMPS
ECT S DECLARATION
l understand my plans shall be used as public records.
OVER IIXIO AMPS
SQ. FT.FLOORAREA
I, y' ,/
/ V's�/ I(
lJ
$/SQ. FT.
SIGNSELEC IUCAL
6 S�
L T
Licensed Professiowl
C d
XOiO
00'000 `o
IIF..... so
OWNER -BUILDER Df:CLANA9'ION
I hereby afford that 1 wn exempt from the Conowca's License Law for the
following monist. (Section 011315, Business and Professions Code: Any city (it county
which requires . permit m consuuel, alter, improve, demolish. or rein..... anmre
SPECIAL CIRCUIT/MISC.
TEMP. MITER OR POLE INST.
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5
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p -ii rrGG
xo{y
W=rn
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Cp
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prior to its smance,isa routines Ne applicant lbrnoch pem+il to file. signed smlemenl
Thal he is licensed purauant to the provisions oflhe Communes License Law (Chapter
9(commencin with Section of Division 3 ofthe Business and Professions Cafe
(commencing )
mind he is exempuherefrom andthe basis Bela, vlleged excmptlon. Any violation of
Serino 7031.5 by any split cam for a permit ubjen, the applicanuoa civil penalty
not more Than f ve hundred dollars (SSW).
Prperi Y PY 6 pensation,
❑ 1, she work. ands n n eis em en ed prof brand corsale sale(Sm. c0nl
will do soucmreisnmimm�deJe Business
fs
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
N
L_�sl•-N\
OUTLETS - SWITCHES - FIRTTIRES
NEW RISIDENI'IALEL[CIA _SQ.fT.
STORIES
TVPE CONSTRUCTION
lesions Cors: Lawrdo
and ons Cors: Tom Comracmr's Law does a.[apply to a
apply lf un owner of
,mr wh h who
nd who or himxlfonhroug. his
ownertywyees, pdsorimprat sucves
aressucbwork
employees, provided that such improvements are not intended ondPoredforenle. If,
improve
OCC GROUP
NIS. UNITS
T 1. '
however, the bmidingor improvement issold within one yeuofcompletion, the owner-
builder w ,It have the burden dprovingthat he did not build or improve gm
ve for Nxof
QTY. Nu UMBINO PERMIT' FEE
soled'
❑ I, asownerofthe property, am exclusivelycontr.eting with licensed contractors to
FLOOD ZONE
"N
onswcl the project (Sec. J(LW, Business and Prnfessions Cade:) The ConvectorsIla
License Law docs not apply manownerefprepeny whobuildsor improvesthereon.and
''RMI'I'ISSUAN
whocomracts forsuch pmjats with a cnnuvclond licensed pursuant othe Contractors
License Low.
ALTER 'T-WATF.N (FA)
s.
17,E SUMMARY
❑ Ism exempt under Sec. , B & P C for Ibis rcsson
BACK FLOW PROTE DEV ICE
OUTSIDE DE P sE
SANITARY Y N_
RECEIPTN
Owner Date
DRAT, OOR.ROOF, REA,COND.
WORKMAN COMPENSATION DECLARATION
❑ Ihembyafrimti+atllmveacertifealeofconsemmselfinsure,orace' .lent
Workers CmployeesnderthisInsurance copy thereof(Scc.3B Cd which
SCHOOLTAX YN
RECF:IPfp
PI% P -PERT'
PARK FEB Y
anna<ertified
rs all employee's under permit.
Policy g
GA. FA. SYS -I IN .4 OUTI-P
a
BU1LDRL(WFVjQK FEES
Cnmpnny
0 $ -FA. SYSTYM-OVER 4 (F )
PLANCHECK FEP, ` O
❑ Certifieiropyishereby famished.
❑ Certified copy is fledwith @"city inspection divisio.
GREASE D 'RI. WASTP NTERCEPTOR
GRADING FEE
CERI'IFICATEOFEXEMMION FROM W KERS'GR
COMPENSATION INSURANCE
AP
SOILS FEf
SHWE ANITARY- ORM EA. 20017'.
ENERGY ME
This section need not be completed lithe annit is for on eh onto dol> -M
or less.)
WATER HEATER ENT/ELECR
I certify that in the perfoncence arthe work for which thin pe 'tlsiss
not employ any person in any manner so ss to becmne subject the
PAID
_L/C/�l
WATER SYS /1'SEATING
NEW RES IiNTIAL PLMIL SQ. Ff.
z
,'�O0
Compenxmion Luws of GolllUml01. Date
C
NMIC13TOAPPLICANT:ILafmrmvkingthis Ccnificmeof Exemtlon,yo houlJ
Dam eipt
'D'I'AL:
F>
� ;
becomesubjecty the Workers Compensation prmitshalofthe Labor Code,you un
r
forthwith comply with such provisions or this permit shall be JeemeJ revoked.
BUILDING FEE
W A
z
CONSTRUCTION LENDING AGENCY
Ihcreby effiml Mauhere isucorewnion lending agency for the perhnmar0ce of
SEISMIC LLE
ELECTRIC FEE
O
F0.
_
U Z
the work for which this permit is issued (Sec. 3099, Civ. CJ
Lender's Name
Lender.. Address
QTY.MECHANICAL PERMIT FEE
PLUMBING FEE
I ccmfy Mat 1 have read this application and nem but the aMve information is
correct, I agree to comply with all city and county ordinances and state laws relining to
building construction, and hereby outhoriscrepresenmtives ofifis city to enrarupoothe
above-mentioned property for inspection purposes.
PERMIT ISSUANCE
MECIIANLCALFEC /a
ALTER OR ADD TO MECH.
CONSTRUCf10N TAX
(We).gree to save, indemnify end keep harmless the City of Cupertino ngdrn
liabilities,' mems, costs add canonizes whichmay many way acme against said City
AIR HANDLING UNIT (TO 10,000CFM)
to can, c of the grunting of In i1. /
AIR HANDLING UNIT(OVER 10,0000 CFM)
S' euro of ppliermt/c t r Date
EXHAUST GOOD(WNUCD
PAID
HEATING UNIT (TO 100,000 BTU)
If RDUS MATERIALS DISCLOSURE
Date Receipt 9
W ill Ibe applicant or famre building ..,at store or handle bassoons material
as refined by the Cupertino Municipal Cale. Chapter 9. 12, and the RaaW and Safety
11 EATING UNIT(OVER 10010(I0 BTU)
TO'T'AL:
VENTILATION FAN (SINGLE RISID)
Code, Section 25532(.).^
❑ Yes ❑ No
licmrfmurebuilding occupant useequipmentordevices whichemit
BOILER - COMP (311P OR 100,000 BTU)
ISSUANCE DATE
BOILER-COME(OVER 100,1X70 BTU)(f#.;t.;'i.=4Znuu2.ars
to declined by the Bay Area Air Quality Management
nc
I� g•1 +q,
EI Yes ❑ No
J'
NEW RESIUEM'IAI. MECH. SQ. FT.
I have need the hazmdotx materials requirmam s under Chapter 5.95 of the
Culifomiv Health & Safety Code, Sections 25505, 25533 and 8534. 1 undernnd That
OCT -6
199
If the building does not currently have a tenant, that it is my responsibility to unity the
ire
contract of the "i mems which must h mel prim m issuance of a Certificate of
fkcuponcy.
/�
0l Y
ISSUED BY:
Owner or authorized agent Date
TO 1-
OFFIC