26998APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO - A
BUILDING DIVISION APPLICATION/PERMIT PLUMBING
-,ys.`,]BUILDING PROJECT TDI?NTIFTCATION; :x_a;.;s',^!„'r
PERMIT NO.
n C (� (� C
L v J J C
BUILDING ADDRESS:
SANITARY NO.
APPUCATIONSUBMJTALDAI
/ `' 1 a�
A*—i dS G UNIT# LOTH
"I hAl
wN ' NAME: I
.( ' • 1y PHONE..: I' —I
/.i safe dew
CONTRACfOR'S�NA�ME�: ��a - 1 LIC N0:
�� rlGl Glx+-� 5 11 Gid 35101
NIC
❑
CONTROL is
R IIITEC/IiNGINEER: ZIC NO:
ADDRESS:
7 !.s{c ave. IUKI.i Tao31
CONTACT: PHONE:
W1 :XP±r. T vlLECnUR.•AgxRM ` p ”" Nd `"'"
QTY. ?P1:ECTRIC PERMITSYd.,,-�kFEE
r •sr�+oat. .•.N.vn'..0 s.P. �.✓ e=.(54i'a. r�'
'�., T' 1; . w4+BUn.DING PERFBTWFO,Ni„'sr01, ;gt
BLDG ELECT PLUMB MECII
PERMIT ISSUANCE
K ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby effimn that l am licensed under pmvisionsof Chapur9 (commencing with
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
PANELS y
UP TO 200 AMPS
Section 7000)of Division 34lhe Business atm Professions Code. and my license is in
full forte and eR
License Class Lic. g
201 - 1000 AMPS
Dam Co...,
ARCHT ECTS DECLARATION
I undersund my plans shall be used as public records.
OVER IOW AMPS
SQ. FT. FLOOR AREA
S/SQ' FT.
SIGNS ELECTRICAL
Limnxd Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUI 154.
1 hereby affirm than 1 am exempt from the Convect&, Licene, Law for Ne
TEMP. METER OR LE M
following reason(S
. ection 7031.5. Business arm Professions Code: My city or county
or Midair any avucluae
which requires a pemtit m construct. slur, improve. demolish, rim ance
pto its issu, also teyuirea the ii'limnt fer such permit to fil... igewA s.,
POWER DEVICES
but, he is licensed pursuant to the Provisions of the Chairman's Llcmx Law (Chapin
9(commeon., with Secede. 7000) of Division 3 of the Business and Pmfessiom Code)
SWIMMING POOL ELECTRIC
VALUATION
or that he is exempt therefrom ate the basis for the dleged exemption. MY violation of
Section 7031.5 by any applicant for a Permit subjects the appliesnnoacivilpendry&f
600
OUTLETS - SWITCHES - FUOVRFS
not dome Ours five hundred dollen (SSW).
❑
INEW RFSmENf1A1. ELECIR_SQ.PT.
STORIES
TYPE CONSTRUCIIOf
will do the work, and the svuctuM is not intended or offeerm for ads (Sc 73/4, Business
and Pefexiom Code: The Contemnors Limine Lew does rant apply m an owns of
property who builds or improves thereon. and whodlses such work himulfm lmough his
ownemployms.pmvided Natmchimprovemenumm,inundednoffeudf&reale. If,
OCC GRO P
.UNITS
ishaWwitldo., yewofcompletion,theowna-
however,Neav,
thegnimprovarcnt
builder will have the burden of proving that he did not build or improve for purpose of
ma
Q1T' PLUMBBIN
sal
FLOOD ZON
qpN
I.uownerofthepeopeny,mteaclnivelychnvaainB with lieenscd donuannsm
comwct Ne project (Sec. 7044, Business, and Profeasiom Cade:) The erConvect&,
Licue Lawdreonotapply, m an ownerofptnpatywhh builds orimploves Naeon,and
-
-
ppEMR ISSUANCE
wh& cmvecu fm such plojecu with a conlacur(e) lices s ed iso malum m th Convector's
License law.
ALTER -ORAINd Vyr - WATER( )
FEE SUMI4fARY
❑ 1 ears exempt under Sec. , B & P C for Nu rtsson-_
BACKFLOW 51l DEV
SANITARY Y N
Ower D Is WORKMAN COMPENSATION DECTARATMN
-
DRAINS&ROOF. D.
SCHOOL TAX YECE�1'g
N
❑ IhcMby off thetihav<acenificam ofmsmituxlf-ivum. me msOBule ofRECEIPT
POWPARKFHE
is
'y 0 i N
Whrken'C&mpenseiion insuaencehrottrtified atpy fbveof(Sc 3800, lab C.)which
__�I ��DD 7
Policy plemploynA.et�a�ht' 0���,� 3z.
O -EAS .1 C.40
BUIDINODIVIIIONFEES
or
OAS EA.SYSTEM VER4l ) at
PLANCHECKFEE
I
'Cc
$ Certified dopy is hereby famished.
GREAS)IRMUMRL WASTE DfrimCEFTO
GRADINGFEE _
❑ Certified copy is filed with Nedry inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'.
GREASE Tbala,
SOILS FEE
COMPENSATION INSURANCE
SEWER-STORM WFT.
ENERGY FEE '
(This section need not be completed ifthepamit isformu handremdagars(Sim,
&r less.)
WATER HEATER WINE CTR
Icenify Nmin Neperfommmmoftheworkfwwhichthisp=ituissued,la I
rot employ any person in any mother w as to became subject to Ne Wisdom'
PAR) -
Comperoment awa&f Califmn;a. Data
WATER SYSTEM/TREATING
Dau RecdptN
Applicant
NOTICE TO APPLICANT. If. al making this Cerificee of Exemption. you sllumd
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
became subject m Jr. Workers Compensation provision of flu labor Code. you mast
foMwiNcomply with such provisions orchis pemdl slWl6e domed evoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that thee u is cmuvuction lending agency for the perfamenu of
du work fm which this fa m it is issued (Sec. Sill Civ. C.)
Lender,
- TOTAL
ELECTRIC FEE
Name
Us &,', Address
I I
PLUMBING FEE
1 testify that 1 have read this application mil sum Na du above udmmatim is;
comest.Iopens, in comply with all city anal county oNinences and arae laws misting in
PE2MRISSUANCE
MECHANICAL FEE
building construction, and hereby walsoriu repMrmulives of Nis dry ad miss upon Ne
above-mmtimud pmpmry for inspection ptvpose.
ALTER OR ADD TO M ICH.
CONSTRUCTION TAX
(We) ogres to save, indemnify atm kap hamate. Na City Of Cupertino eigaunt
Iiebilitice,judgmmu,ma. and eapenses which may in any way ecrnMagainst said City
AM HANDLING UN'T(TO IO,o00 CFM)
mcmtregaellee&flhegxnting Of Nis Pe L
.
AIR HANDLING UNIT (OVER I0p00 CFM)
Sigasureof ApplicanYComrxtm Dam
EXHAUST HODD (WMUCT)
PAID
BEATING UNIT(TO 100.000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dae Receipt0
FIEATIN,G UNIT (OVER 100,000 BTU)
TOT
Will the applicant or fugue building occupostmue or handle hoardous materiel
as della d by the Cupertino Municipal Code, Chapter 9. 12, and Lha ReaIN real Safety
VENTD.ATLON FAN (SINGLE MIDI
ulls
Cale. Section 23512(4)T
❑
13 Yes N&
BOMB- COMP (JHP OR 1110,000 BTU)
ISSUANCE DA TE
Will Ne epplicancorfmurebuildin as rot
g upantay
BOILER-COMP(OVER 100,1100 ETU)
Areas Quality Management
Ontario? hue air conuminanu as defined by Ne Bey Ma AU Quality Mmagemcnt
DiaWct?
❑ Yes ❑ No
NEW RESIDENTIAL MECH. SQ. PT.
AT -
r pA
I have lead the hiseSafety Coe. masons 5505,2553u under 34.1 6.93 of the
Cadif ail indoeth snoteryCedyhave. eaas25503,titis and 25SJ4.lundanundhist
if the building des not currently have a ¢nanL fha it is my Mapomibiliry, m notify Ne
of du M9u ens wId hh/�lass(y�f�l�p���r mei of. Certificate of
J
nsdv '
kq
SEP 1 �.
ZZ1
1Xcup:t cr.
—`'�J
LCAT—/�I6V�l/
Owner& N&d agent Dale
41f r r ,. .,..1 t
ISSUED BY!
TOTAL:
OFFICE