26100 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO n ILDIN. ELEC RICAL I'IiRMTNO. ^ O a� O O
APPLICATION/PERMIT PLUMBING.MECBANICAL L 1
BUILDING DIVISION -BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: • , SANITARY NO. �APPLICATION SUBMITTAL DATE
Q G 6 wO UND# LOT# y
NESS NAME: PHONE: COM'SACfOS'S NAME::. 1.I.Cs
CIIN * �` s/I! IG[I� w`✓� /��I23
N/C CONTROLN
PRCIIITECT/IiNGINF.ER: Y LIC NO: ADDR1iS3:14 cYrq V
1 F' 0Na 0 /J,—ceryl/
CONTACT: PHONE:
QTY. IiLECI'RIC PERMIT FEE BUILDING PERMIT INFO i
B ELECT PLUMB MECH
PERMIT ISSUANCE ❑ 0 ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
O.ZPOO Ihereby7")of Di Natl 3 atthosedinss and rotes ions Coder and mmecense wish
4100 Section 7")of Division Jorcensedndeand Professions Coda andmy is PANEL'S
F W oa full h:rco and off, I
as coel,# G7aa93 UP ro 200 AMPS
xoI-I000 AMPS
F-rOi,N
ARCHITECTS DECLARATION SQ.FT.Il.00R AREA S's TT.
ZOrn� OVER 1000 AMPS O
O Zn 5O I understand my plana shall be used its public records.
y ; SIGNS IE1.13CI'RICAI.
6 U Licensed Professional OWNER-RUILDER DECLARATION SPECIAL CIRCUITIMISC.
Oa 1 hereby affirm that 1 am encmpl form the Commences License Law fur the
W 3�m fallowing nous.....(Section 71131.5.Business and Professions Cade:Any city t ar roany t TEMP.METER OR POLE INST.
which requires issuance,permit rIlie am sthe altar,improve,demolish.or rcpnig ed structure
}� primo i¢ ensedralso¢go the previsions
of the Co pcmtiuo filLicense
La statement POWER DEVICES
O that rn is licensed pursuant m the provisions of the thenwnm's License Law(Chapter
m a�' 9(cont he is exemith 7000)of Division Softhe ed exemption
Professions AnyvCMe) SWIMMING POOL ELE,FIXT /�, yy,l]ATION
J=K, RIC
ordust boheisex by
rcfromane the basisroahe is the applicant
civil penalty of OUTLETS-SWITCH S-
2 Q Section 7031.5 M1y any applicant for a permit subjects the applicanno o civil penalty of FIXTURES
t come than five hundred dollar(SSW).
C a n❑ 1,asownerofthepmpcny,ormyemployeeswithwugesasthelrsrlecompensation. NEW RFSIDENTIAI i fi .Ff. TORIES TYPE CONSTRUCTION
4S will do the work,and the structure is not intendedoroffered forsale(Sec.]044,Business ID I
and Professions Code:The Contowmes License Low does not apply m an owner of /
propcny who builds nrimpmven thereen,nnd who does such wnrkhimulfor lhroughhis RIL
t e dedthat such improvements t t declooffered forsals.If.
IxC.GROUP HES.UNITS
raddeemployees,s,pmvi pis sold n hin n..in en
er,menneDomiiicaI po it,thaldwnninnneyearompriletirn,theewnar- ATE T
hoeJer will kava Dominica dl'Proving Ibnt he aid n..t anile ar improve tun Purpesc of
me.).
❑ Las ownernfthepropeny.nmex<lusively convecting wiN licrnxdconwnoa to QTY. PLUMBING PERMIT FCC ----FLOOD ZONE AI'N
umvuct the project(Sec.7144,Business and Professions Code:)The Comovcmrs
License Law docsom apply In an owneoofintramy wholaddsor improvesthereon,and PERMTI'ISSUANCE
who contacts ftrsudt projects vionme mmc(..r(a)licensed pursuam to the Comractods
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 em eacmpt under Sec. ,B&P C for this roman BACK R.O W PROTECT.DEVICE - OUTSIDE FEES
SANITARY Y—N
—
Owner Date RIECEIVI'p
DRAINS-FLOOR,ROOF,AREA.COND.
WORKMAN COMPENSATION DECLARATION SCf100L TAX Y N
❑Workers
Co penruffismion Insue a rance
ma
a scam of coram toulf-insure,or Lab C.)e te ofwhich FIXTURES-PER TRAP RECEIF'Tp
Wnrkers'Crmpensmiun lnsurwce ornccnified copy thereef(See.3800,Lab C.)which � PARK FEE YN
covers all employee's under this peom'u. GAS-EA.SYSTEM-]INC.4 DISH.E, - RHCEJJfr#
policy# BUILDING DIV ION FEES
Company GAS-PA.SYSTEM OVER 4 HEA) PLANCHECK IEE
❑ Cenifed copy is hereby burnisher. I
If 0
❑ Coddled copy is filed with the city inspection division. GREASP/INDUSTRI.WASTE INTERCEPTOR GRADING FEE
CIERTIRCAT11 OF EXEMPTION FROM WORKIiRSGREASETRAP SOILS FETE
COMPENSATION INSURANCE
(This scaionnaJ notMcomplemdilrhe permit is(crone hundred dollars(E 100) SEWER.SANITARY-STORM PA.200FT. EiNCRGY FEE
lea.)
I cenil'y flim in the performance ofthe work for which this permit is issued,l shall WATER BEA'rBR W/VENT/ELECTR
not cm y person in any manner, so Ik5 to pec- pybject to the Workers PAID
O z Co licamax
mtioan WATER SYSTEM? RRATING D Rccciptp
PP `^ , 1 Id NEW RESIDENTIAL PI-MB. SQ.FT.
O NO'hIGE'TQ APPLIGAN'I':IL after making this Ce(ifw(e of Bxemptinn,yous uta TO'T'AL:
become subject the Worker's Compensation provisions M the Labe Code,you mud
> forthwith comply with such previsions or this permit shall be Seemed revoked. BUILD 'E
Q CONSTRUCTION LENDING AGENCY SEI . -.
1 hereby affirm that there is u construction lending agency for the performance,of
L) O the work for which this permit is issued(Sec.309],Civ.C.) TO'T'AL: IELIECTR IEEE
Lender's Name PLUMBING PEE
F Lender's Address QTY. MECHANICALPF:RMIT FEE
U I certify That I have read(his application and state that the union Infommtion is MECHANICAL Fri.
correct.l agree In comply with all city and county ordinances and state laws relating to PERMI'TISSUANCIi
buildingeottsvuction,and hereby nuthodu representntiveso(this city to enter upon the
maws-memiuneJpropertyfor ins inspection u ALTER OR ADD TO MECH. CONSTRUCTION AX
(•) 7 Pe purposes.
F7 (We)agree to save,indemnify unJ keep hannleus a City of Cupertino id City
Iluhilif s,juJ mems,cods unJ expenses wjtich meyl ny way accrue against euiA City AIR IIANDLING UNIT(TO 10,000 CPM)
in co ce of the grwtin (Nis Get
Z 7�o AIR HANDLING UNIT(OVER IQIXq CFM)
m um of Applicant/ConloneFd Date)) EXHAUST HOOD(W/DUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or form building occurring mrc we handle harardous mmerial
ns refund by the Cupt Municipal Code,Chapter 9.12,and the Health and Safety IIEATING UNIT(OVER I0d0W BTU) TO AL:
Code,Section 25532(x)'! VENTILATION PAN(SINGLE RESID)
❑Ycs ❑Na
ISSUANOK
Will the applicamrr future buildingnecupant meegripmenmrdevices whichemit BOILER-COME(31111 OR 100,000 BTU)
homfors all contaminants is dofneJ by the Bay Arc.Air Quality Management BOILER.COMP(OVER 110,01X1 BTU)
niddet+ p� pp
13 Yes ❑No NEW RESIDENTIAL MECH. SQ,FT. PPS ' D
I have rend the haranlors mmerims requirements under Chapter 6.95 of the e_��
ty I��
California Health&Safely Code,Sections 25505,25533 and 25534. 1 unacrsmad Nat _ l
if the building docs not currently have a tenant,that it is my responsibility to notify the �11'/'/ /
cupant of the requirement u syyi h ud be met prior m issuance of a Cenificam or rs
Circuit.,
Owner or authorized agent Dale TOTAL: ISSUED BY'. f
OFFICE
i