26009 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BIIII'61NtrEEF.CMCA, PERMIT NO, 26009
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APPLICATION/PERMIT PLUMBING-MECHANICAL L v
BUILDING DIVISION BUILDING PROJECT IIIEN'FIFICAJ'ION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE.
/ O/13-7 //Il sl-c kjiorl 94XUNIT I.OTY �\
OWNERSN PII •���� CONTRACTORS NNAME: LIC NO: NIC CONTROLp
S re:
•ARC IT.CI7ENGINHER: LIC NO: ADDRE5 / ❑
CONTACT: PHONE JIVL
QTY. RLECTIM16PERMIT FEF, BUILDING PERMIT INhO
BLDG ELECT PLUMB AIFCIi
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
-
/
nzz I hereby affirm Nal l an licenudunderprovisioneofChVuer)marranemingwith JOB DESCRIPTION
FOO Section 7")of Division 3.(the Business and ProfessionsC e,and my license is in ppNEfS
C W full force and eff ��(
Fzd License Cles L g 7 r'7 UPT0200AMP5 921
y a y Data Contrecmr 201-1000 AMPS
'LOrNn� ARCI3ITECT50 OYER 1000AMP5 SQ.PT.FLOOR AREA f/SQ.FT.
O Z— I understmd my Iws shell be used ss public records.
P y t f.V SIGNS ELECTRICAL
g��J� Licensed Pm(essional
OWNER-BUILDER DECLARATION SPECIALCIRCUT'/MISC.
U MI hereby affirm that I am exempt from the Contractor's License Law for the
tofollowing reason.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE MST.
on which requires a permit to construct,alter,improve,demolish,or repair any structure y u
<� priormiaissuaa.elm quircsNeapplicntfmrsuchp mit tofileasigndsaement POWER DEVICES m i
G O but be is licensed pursuant to the provisions of the Contractor's License Law(Chapter I�
o.XOK 9(commencing with Section 7000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC ' ��' �y' VALUATION
W_m onhat he is exempt herefrom and the basis for W alleged exemption.Any violation of OUTLETS-SWITCHES-FIX'1"IJRES
1-, C Section 7031.5 by anyapplicam fora pennitodeacts theappiicanno a civil penalty of
c not mom than Eve hundred dollars($501). .
C p ElI,asownerofiheprnlmny,ormyemployeeswithwugmustheirsolecompemadNLW RESIDENTIAL ELECTR S FT.on, Q STORIES TYPE CONSTRUCTION
will doubt,wmrk,vrdrhe structure is netimandedoroffbed forsale(Sec.]614.Business
and Professional Code:The Conoacmrs License Lim,does not apply to an owner of
property who buildsorimproves Hereon,and whod«ssuchworkhimselforthrough his OCC.GROUP RIS.UNITS
own emm
ployees,providaHhatsuch improveenes unnot Intendedorofferedforsale.If,
however,the building or improvement is sold within ane year of completion,the owner-
builder .will have the burden of proving that he did not build or improve for purpose of TOTAL:
le.).
❑ I,as owner oftheproperty,amexclusively contracting with licensed conuacronm QTY. PLUMBING PERMIT FEE .FI.00D ZONE APN
consrom the project(Sec.7044,Business;roll Professions Cartel The Contrectme
I.icenulawdoesnotapplytomownerofpropenywhobuil&mo pmvesther ,end PERMIT ISSUANCE
who contracts forsuch projects with acontramor(s)licensed pursuant othe Contmcmr'e ALTER (FA)
License Law. FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this mason BACK FLOW PROTECT.DEVICE SANITARY Y DF�F.S N
Owner Data RECEIITM
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Ihereby affirm that l have a certificate ofcomenno self-insure,ora ani0cate of F7XTURFS-PER TRAP RECEIPTa
Well 'Cempenm in,umnceoracart;Gedmpythemos(Sec.3800,LebCJwhich PARK FEE Y N
oven all cm a da Ibir e_ ry rrQl.(�(/�q / GAS-EA.SYSTEM.]INC.4011TLf:TS REIVISIOM
arwayk-- � N BUILDING DIVISION IF.Ef
Company AJb4f na— A GAS-TA.SYSTEM-OVER 4(HA) PLANCHECK FEE
� ❑ Ce ;lie copy rs hereby l"umrahcd.
mfred copy is fled with Ne city inspection division. GREASE(INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF FAEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(Phis section need not he completed lithe permit is formal hundred dollars($100) SEWER-SANITARY-STORM EA.203FT. ENERGY FEE
or leu.)
I certify that in the perfornsnce of the work four which Nis permit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ any pvson in any manner so as to become subject m the Workers' PAID
Compensation"awl.f Celifomie. Data WATER SYSTEMMIEATING Dale Receiptp
Q z Applicure
z NOTICE TO APPLICANT:If,diet making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
t--r become subject to Ne Worker's Compensation provisions of the labor Code,you must
> forthwith comply with such provisions or this psmdt shall he domed invoked. BUILDING FEE
aCONSTRUCTION LENDING AGENCY SEISMIC FEE
VZ I hereby affirm that there is a conauumion lending agency for the performance of
the work far which this permit is issued(Sec.3097.Civ.C.) TOTAL: ELFCTHUC FEE
Lender's Name v
O F ,cadds Address QTY. MECHANICAL PhRMIT PER PLUMBING FIR 7.
F,
V I certify that I have mall this application and eats that the above information is
correct.lagr«arcomplywithallcityandcounty mdinaness and state lows reining to PERM IT ISSUANCE / MECHANICAL FEE
Ln building consmrvion,vm h by euNoris nativesof Nie city to enter upon the CONSTRUCTION TAX
V z armee-mention Ipmpcny rinspectionp es. ALTER OR ADD TO MECH.
(We)e lm= cmnify end «p ennle the Ciry mf C vino against
liubili ,j g cros,c mda.,emai hic mayI y,myacery against said City AIR HANDLING UNI'((TO 10,00(1 CFM)
inc c o(Ne ting of
/ AIR HANDLING UNIT(OVER 10,0011 CFM)
gnat sofI EXHAUST HOOD(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOS RF. HEATING UNIT(T0100,000 ETU) Date Racapi#
Willtbe appllcam or future building occupant stom or handle hazurdmis mntedal HEATING UNIT(OVER 100,00)BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,end the Health and Safety
Cade,Section 255]2(ul'1
❑Yes C e—P VENTILATION FAN(SING LE ESSIG)
Will air co icanmrfoture building occupantuseeyuipmir Quality
Management
BOILER-COMP(3HP OR 10.000 BTU) ISSUANCE.DATE
harerdom air contaminants u defined by the Bey Am Air Quslily Msnagernem BOILER.COMP(OVER 100,000 BTU)
District?
❑Yes NEW RESIDENTIAL MECH, SQ.Ff. P Q p�
1 have read the lea"on, ateriels requirements under Chapter 6.95 of the "9 U
CnlifomiuJHufety C pions 25505,25533 and 25534. 1 undersand Nat ifthe boilacurtcn y avec nam,thou it is my res nsihilit to notify the {��f1,11V/.1 nremeto ich t be mat prior to is once o Ce e¢of0c L r otryl1 ��,
wnenr amhorized' pea ISSUED BY: lr �
OFFIC