26211APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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CITY OF CUPERTINO BUR'Ifl'oo.'a"n"
APPLICATION/PERMIT PLUMBING.-MECIIANICAL
BUILDING DIVISION BUILDING PROJECT WENTIF'ICATION
PERMIT NO.
26211
BUILDINgG ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
� �1' , 1
�/✓x12a Ws O` ^Y UNIT#
\ /Ci
13�J v AJ—O 1 LOT'
PHONE:
OWNERS NAME: �C
l..J✓G I`ZY G Isrl -
CONTRALTO 'S NAME: r LIC NO:
N/C
❑
CONTROL N
R
ATPIiCT/IiNG EER: �ON
IGIC NO: I&S
ADDRESS:
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
L E PLUMB MECH
(` ^ /''�%
1 Q IJ Sl O a2 L� 1 /O
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm far l sum licensed under provisions ofamplar 9 (commencing with
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
PANELS
Section 70o0 of Division 3 ofthe Business and Professions Code, Nd my Beene is in
full fame and effect.
License Clan Liap
UP TO 200 AMPS
Date Contnmor
201- 1000 AMPS
ARCHITECTS DECLARATION
I understand my plans shell be used as public records.
OVER 1000 AMPS
SQ. FT, FLO`01 AREA
s .
$/SQ. FT.
SIGNS ELECTRICAL
1'••1r'
Licensed Rofesouional
OWNER -BUILDER DECLARATION
SPECIAL CDtCUIT/MISC.
1 hereby affirm that 1 am exempt from the Contractors License law for the
TEMP. METER OR POLE INST.
following reason. (Seaton 7031.5, Co
ions Code: Any city on coumy
construct, a.,, land ve, de
which requires a permit to parestealar, improve, demolish. or repair any smement
prin thriceiscant furach a. If seaman,
POWER DEVICES
hesliceuancgalsorltoth Consumers U.
La
than he is licensed pursuant m the provisions of thethe uawors Lice mu Lawns Coder
9(commcncing with Section 7000)of Division 3ofthe Business and Professions Code)
Ortho heir1.5by therefrom and the bamotsubjthe of
Section say cts the exemption. civiny l
a Pamir subjects the epplicer to .civil penalty of
AMMMING POOL ELECTRIC
VALUATIONI .
—
OUTLETS - SWITCHES - FIXTURES`,_
than iv dvert damfor
not mom than rofhundred dollars yemp.
o
❑ pr prny,ormyemployeuwith wegesutheiraoleconpenseuon,
NEW RESIDENTIAL ELECTR S ft.
Q I R
B� B�TIDglli�
TYP CONSTRUCTION
oduew k,mdt
will da thewons and the edi
imemense
eelelply
LL I�.. L�11'1
I
1
LaPo
Code: The Convectors does
he Comisro to a, owner of
and Prosity who Law does not apply to st owntt
'
who d is
pmpcny whobuildsorimprovu thereon, and who does such work himulfotlwugh his
imp
neyearndedmpletiod forownrrL
\
r
C. R P -
S. UNITS
T
however, theesilding rimprooch
is sold ithot thrower-
however, ill have the burden of Proving
i that he didnoneyer or improve for
builder will have the burden of proving that he did not build or improve for purpose of
O
s
QTY. PLUMBING PERMIT
sale.).
❑ I, as owner property.amexclusivelyconvudngwithliremadeenuacussm
APN
mummer, the project (Sec. ]044. Business end Professions Cale:) The Convector's
License Lowdoes not apply to mownerofpeoperty who builds orimprovesthemon,and
PERMIT ISSUANCE
who contracts for such project with acentraamr(s) licensed pursuant m the Compactors
License Law.
ni
PETER - DRAIN&VENT - WATER (EA)
PEE SUMMARY
❑ ren exempt under Sec. , B & P C forNis reason
BACK FLOW PROTECT. DEVICE
SID
SANITARY Y N
— #
Owner Date
LOOR.
DRAINS- FROOF, AREA, COND.
WORKMANCOMPENSATIONDECIARATION
SCHOOLTAX YCC N
❑ I hereby affirm thin l have. cerificumm prem to self-insum,or acertificme of
Workers' Compensation insurance or a certified copy thereof (Sec. 3800, Lab C.) which
coven ell employee's under this permit.
PolicyM
CEIPTp
PARKFEE AV0,4Y N
RECEIPT #
DI GDIVISION FEES
PLANCH
FI%TURES- PER'TNAP
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
Company
❑ Certified copy is hereby famished.
GAS - EA. SYSTEM -OVER 4 (EA)
GREASMISIDUSTRL WASTE INTERCEPTOR
GRA
❑ Codified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOJS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
(This section reared not becompletd ifdrepermit is forme hmdrtd dedllas(SIW)
m leas.)
WATER HEATER WNEN'T/ELECI'R
I certify that in the performance of the work for which this permit is issued, l shall
not employ any person in my manner so as to became subject to the Workers
PAID
Compensation Lawsof Califomia. Date
WATER SYSTEMITREATING
Date Rx' p
Applicant
NOTICE. TO APPLICANT, If, after making this Cerofinu of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
became subject to the Workers Compensator provisions of the labor Code, you must
foMwith comply with such provisions or this permit shell be deemed revoked.
BUILDING
SEISMICJRXA,/ Vii
CONSTRUCTION LENDING AGENCY
1 hereby affirm that then is a examination lending agency for the performance of
the work for which this permit is issued is.. 31190. Civ. C.)
TOTAL:
CLE
Laders Name
QTY. MECHANICAL PERMIT PEE
P, M NGFEE
Lenders Address
1 certify that I have read this application and sate that the above information is
correct. l agree m comply with all city and county ordinaries and state laws minting to
PERMIT ISSUANCE'
MECIIANICAL TEP.
building construction, and hereby auNoriumpreununvesofthis city matter upon the
property for inspection pues.
above-mentioned rym
ALTER OR ADD TO MECH.
CONSTRUCTION T X
Wilagree to save, instantly and kap hu mess Ne City of Culmina against
Iiabilities,judgmeme,cmu endexpenseawhichmay, inany way nttmeagninsteaid City
AIR HANDLING UNIT (TO 10," CFM)
AIR HANDLING UNIT (OVER 10,W CBM)
consey nee of the rmiL
Vs
Signature of Apprwn or ate
EXHAUST HOOD(W/DUCT)
PAID
HEATING UNIT(TO IW." BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dau apt#
Willits, applicant or future building occupant more m hurdle heaerdons muurial
as defined by the Cupertino Municipal Code, Chapter 9.12, end the Health and Safety
Code, Section25532(a) 7
11
❑ Yes ❑ No
i
HEATING UNIT (OVER I W,OW BTU)
VENTILATION PAN (SINGLE RFSID)
ISSU
Will the applicanmrfuare buil&ngmcupntux Nuipmentordeviceswhichemit
BOILER- COMP(3HPOR IW,WOBTU)
"
BOILER - COVE(OVER IW,00I)BTU)
hassrdmus uir contaminants am defined by the Bay Area Air Quality Meragemem
District]
9 R 1994
NEW RESIDENTIAL MECH. SQ. PI'.
Yes ❑ No
11 Yes
1 have read the hasardous materials ar,por mems under Chapter 6.95 of the
011 Y Ur wrcmI nu
California Health & Safety Cade, Sorters 25505, 25533 and 25534. 1 mrderstmd that
if the building does not currently have a tenant, that it is my responsibility to notify the
excupar of the reyui,emems which most be met Juno, to issuance of to Caffeine of
Occupancy,
I,SUEDBY�.
Ownermathndisdagem Dore
T