26710 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELF. RI AI. PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 267101
BUILDING DIVISION BUILDING PROJECT'IDENTIFICATION
60 0
BUILDING ADDRESS: SANITARY NO. APPLICATION SURMITI'AL DATT:
q2J� UNIT# LOT#
OWryl]R N MG �/+ R.yrl� ONE' CONTRACI'OIt'S NAME LIC NO: N/C CONTROL#
ITECI'/ENG EER:•/`—`/�•J1TV-lL'�V. LIC NO: ADDRESS: ❑
.ONTACT: PHONE: QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB M[CH
PERMIT ISSUANCE ❑ ❑
LICENSED
i,h.I a DCONTRrdc,,o mmam C1oLdmN APPLIANCES-RESIDENTIAL JOB DI3GClt{pl(D
pyy Therebyaffirm CENSE liCONTR CI OR'S DECLARATION
ECL RATI 9(cnmmen<ingwi,h yL;I,�/I
FICOF Section 7000)of Division Sof Inc Bmincesund Professions Care,and my license is in PANELS
full force and effect.
<Zm Limme Class Lic.It UPT02MAMPS i
y<� Da¢ Common, 2(11-IIXW AMPS
ZO,z ARCHITECTS DECLARATION OVER 1000 AMPS Q.FT.FLOOR AREA $/SQ.F1'.
O i_❑ 1 rmdcaond my plans shall be used res public records.
vs f'J SIGNS ELECTRICAL
KKK� Liemosl Pmfccsimml te< OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
xea. 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
L a Q following reason(Section)B3 LS,Business and Professions C«Ie:Any city ar county TEMP.METER OR POLE INST, y/
,n J which requites o permit ,,conswa,alter,improve a of repau m swctme
S'LL"1YF gno,to its istaamse,isurequires thea rsuchperm e,File asigncd statement POWER DEVICES
p�j pC�O that he is lice pmvbmm,.ffht Cmnm,, 'sl.icense Law(Chapter
dXoW 9(cr cingwith Sation7000)of Division3ofthe Busi es and Rofessions Cade) SWIMMING POOL ELECT RIC VALUATION
,M_ o 1lua 11 axempr therefmm and the basin for the alleged emp,iim Anyviolatlnnuf
FZ� Section 51.5byanyapplicaniforapermitstbjxw Neaplicmttoacivilpenaltyof OUTLET'S-SWITCHES-FIXTURES
K F< n nren nt five hundred dollars IS W).
_o ❑ Laso ncroncapmperi ormy p wi ag sastheirsolecon'tramum, NEWRFSIDENTIALELECrIt _S('FT. STORIES TYPIi CONSTRUCTION
y3°_ willdo,he ork,tndthearme, mor oHere mosale(Sm.7044.Business
and Pointso 'ode' C r'.,License Law d -s not apply to an owner of
propenyw OIL c"he rte" nk himselfonMntgh his
empi ecthrtsuchina semred norm ndedrofferedforsale.If, (>CC.GROUP RIS.UNITS
hromIm. ebulding impmvememiss ohin one year ofrompletlon,the owner- TOTAL:
builder II haw urden of prov' at he did not build or improve for purpose of
Or
❑ I, crof m Dep ny,aeaclusivelycontmeting with licensed contractors to QTY. PLUMBINGPERMIT FEE FLOOD ZONE ApN
smor 0 e poi re.7044,Business and Profusioru Code:)The Common.s
LicenseN not apply manawnerofFrrpeey who builds or improves thereon,and PERMIT ISSUANCE
who cono-ecu fo,meln pnrjects walmemnarm,B)licensed pmatunOo the Contractors ALTER- LEA)License Law. DRAIN EA FEE SUMMARY
❑ I am exempt under Sec. ,p&P C for this reason BACK FLOW PROTECT.DEVICEOITI'SIDE FEES
SANITAKY Y N
Owner Date AREA,ROOLI
DRAINS-FLOOR, , EA,GOND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y_N
.rI reby Compensation Insurance
prancecertificate
or a rein0fcrnuntmself-m.380r Labit C.)wmof FIXTURES-PER TRAP RECEIPT'#
('. workers Oall"set,aorde hoprmit, fed copy therrnf(Sa.38o0,Lab CJ which PARK HE Y N
n all employees under this permit.
Policy GAS-EA.SYSTEM-1 INCA 00'I'LEI'S RECEIPT#
BUILDING DIVISION ZEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK HE
❑ Certified copy is hereby fumishcd.
❑ Caddied copy is filed with the city inspamrm division. GRE\SEffNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETIOU, SOILS FEE
COMPENSATION INSURANCE
(This section need nor be completed ifthe permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY ME
or less.)
I certify that in the permommeeofthe work for which this panni,is issued,Tshall WATER HEATER W/VENT/ELECTR
no,employ tory Person in any manner so as to become subim,to the Workers' PAID
A Compensaion Lawsof Califomia. Date WATER SYSTEMTRF.ATING Data a
Reiptp
Applicant
z NOTICE TO APPLICANL If,aper making this Certificate of Exemption,Imi,leuld NEW RESIDENTIAL PLMB SQ.ET. TOTAL:
(q
Names,subjecttothe Worker's Com,smsmion provisions ofthe labor Code,you must
forthwith comply withauch provisions on hi,prrmi,shall be dermcdrev Ard. BUILDING FTE
IL O CONSTRUCTION LENDING AGENCY SEISMI 1;E
� z 1 hereby affirm that there is a concoction lending agency for the performance of
U C) Inc work for which this permit is issued(Sec 3W7,Co.C) 'TOTAL: ELECTR C
Isndcrs Name C) U Lender,Address QTYKFFICE MECHANICAL PERMIT FEE PLUMBINGFEE
1 anify thm I hove read this application and.otos that rhe above infoms um.is
entree,. I agree to comply with all city and artery ordinances and sane laws rcWin,I. IT ISSUANCE MECHANICAL FEE
F" ,0 Isildingconstoolmn,anthembamalo ,c repreaeamfivesefthiscity wenterupon Ne
L) z abovememioncd progeny for inspection purposes. ORADDTOMECH. CONSTRUCTION TAX
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Imbiliha dgmengcos andeaormes'hichmayr y wayacerteagainmsao City NDLING UNIT IU,opO CFM)
I an of the gr tin is perr�.y�, 7 n
,LYJG/-l�lil/R/ Z NDLING UNIT IgOIXI CFM)
r Sr cneonam'Applmam/7—n, or �e ST HOOD(W/DUM)
PAID
HAZARDOUS MATERIALS DISCLOSURE NG UNIT 100.X10 BTU)) Data Receipt#
Will the applicant or form building occupant store or handle hazardous material
as'W by the Cugcnino Municipal Code,Chapter 9.12,and the Health and Safety NG GISH(OVER 100,000 BTU) TOTAL:
C V,S«tiE 25�32(e)7 ❑No LATION FAN(SINGLE RESID)
:4�
Will the npplir torfmure buildingcecupant usccquipmem mdevittswhich emit
-COMPCITIPOR 100.(040 BTU) S �urdmn%air comaminams as defined by the Bay Arco Air Quality Management R-COMP(OVER 100,000 BTU)❑Yes ❑No ESIDENTIAL MECH. SQ.ET.I have read,he haz.,aid mmm�al,mquiremems under Chapter 6.95 of theCalifomia FleahM1&Safery Qdc.Scmions 25505,2553?and 25534.1 undersand thatM_- �9ifthe buildingdoesnm currently hoven moan,,,Imr it is my rcspmsibility m notify theM.n/#/M'sccuPao of the neem ermms which must M1e mer poor to issuance of a Imuticam ofOccupancy.Owncrormhrl'md egem DareTOTAL ISSUED BY: 1
OFFICE