26307 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY CUPERTINO .1111.BTN(:-F.LJ. rit Ai. PERMITNO.
OF
BUILDING C DIVISION APPLICATION/PERMIT PLUMtlING-MECHANICAI. n C O
tlUll.l)INC.PROJR(:I'IDI:N'1'IFICAI'ION L v
11LDINGOADO G55: Vol SANITARY NO. APPLICATIONSSUUBMIITI'ALDATE
3 9 UNIT'# I.OT# 4.- fIO-0—ivr
OWtyIiRSNAMI!: /�� '•� PHONE: ONTRACfOR'S NAME: LIC NO: NIC CONTROL# -
i1+e. 1 V 7zs-! 6
ARCHITECOENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEB BUILDING PERMIT INFO
BLDG FyEQ/ PLUMB MECH
PERMIT ISSUANCE / fO ♦Y�a7(�"
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
pKZ IMAbyaffrm that l am licensed underprovisittsofaripter9(commenting with
1400 Section 7uo@of Division 3ofthe Business and Professions Cann,and my license is in PANELS
fy-W C full tone and effect �D
F V w License Clasr Lic.# UP TO 200 AMPS
rn y Dote Convector 201-I"AMPS
Z FOyZ ARCHITECTS DECLARATION OVER 1000 AMPS SQ.IT.FLOOR AREA $/SQ.FT.
OZ-0 I understand my plans shall be used as public records. I�
9_ SIGNS ELECTRICAL
Licensed Professional
0w OWNERBUILDERfrom
the Con TION SPECIAL CIRCUIT/MISC. �O
OyF I hcrehy afMn that 1 am exempt from the Conwetor's License law for the
Tp; Oao fuilowingteason.(Section 7031.5,Bmimaua And Professions Code:Any cityorc...ty TEMP.METER OR POLE INST,
F.wJy which aquima s permit m construct alter,improve,demolish,or repair Any Amoco.
6 �
prior to its borne..N.a4nie.theupplicant At pesmitto fileasigned atatemem POWER DEVICES
_Q0 the,he is licensed pursuant to the provisions of the Continuities License Law(Chapter
e 9(commencing with Section 7")ofDivision3ofthe Business and Pronasions Cale) SWIMMING POOL ELECTRIC VALUATION
or that he is exempt mammon and the basis for alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
ZG Section 7031.5 by any.pplicantfora permilredayn.theapplicennoacivilpmdty of _ {. 1
C not mom than five hundred dollvs($5007. NEW RESIDENTIAL ELECIR S .FT.
p ❑do
wrk,afthrpmpeny,ormyrmpinyeeswi0wagesastne(Sec.c0mpensetion, _SQ.FT. TYPE CONSTNUC'1'ION
yJ° will d0thework,and then o Camucture is not i.Lica n,Law rad
A,Apply to an owner
of
one Prafelortywh ons Code:The yeathe tore License Lew does nm apply to oro owner of
own con whobeadsorimprovrathereon,and whadoes such worenimsseftforr gh his
however.thers,pingor improvement himpmvememaarcneyeardedopletio ,theo e.Ir, OCC GROUP RES.UND'S
however,the buildinguren ofpis sold within one yea of completion,the owner
builder will have the burden of proving that he did not build or improve for purpose of
Asia.). TY, PLUM13INGPERMIT FEE FLOOD ZONE APN
❑ 1.As the project pmpeny,am.ifinei Ad limmistiming,Cdth.;)Th Commionto Q
construct the project(Sec.nano Business and Professions Code:)The Contractors
License l.uwdceauchapply
Landeals withacofpropeny who builds ouant India
thereon,and PERMIT ISSUANCE
whocomraws(t such projectswithecanvocmr(s)Iicenxd punumttntMConunemre
LicewLaw. ALTER-DRAIN&VENT-WATER Ip) FEE SUMMARY
❑nl am exempt under Sec. ,B&P C ft Nis moron BACK FLOW PROTECT,DEVICE SANITARY O Y DD�.F. N
Owner Date• DRAINS-FLOOR.ROOF,AREA,GOND. RECEIPT#co WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
EImself-imrqThereby affirm thetlhnvev cenifcam of consent u ..aceniliawa.f
FIXTURES-PER TRAP RECEIPr#
Worten'Compenmti0n hturantton ttnifiedarpy thereof lSec.31100.[AbC.)which PARK PEE Y N
en nl I empl.,ana under this Permit GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEB'T#
Policy As BUILDING DIVISI NF ES
Company GAS-EA.SYSTEM-OVER 4 HA) PLANCHECK FEE
[I Certified copy is hereby AuArMal.
❑ Certified copy is filed with the city inspection division. GREASWINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE MAP SOILS EEE
COMPENSATION INSURANCE
(This mctionnsed not becompletW ifthepeunit is for one hundred dollars($100) SEWER-SANITARY-STORM HA.200FT. ENER
or laws)
GY FEE `
I certify that in the perfarna....f the work for which this penult is Issued,Ishall WATER HEATER W/VL'NUELECIR
not employ any person in Any manner so As to become subject to the Workers' PAID
Compensutionlawsof Celifomia Data WATER SYSTEM/TREATING Date Receipt#
rQ O NOTICETOAPPLICANT:It tin this After mACertificate of Hxem &.unn, o should NEW RESIDENTIAL PLM 5Q Fr.
ry become subject the Worker's Compensation provisions of the Labor Code,you must TOTAL:
w forthwith comply with such provisions t this permit shall4 deemed revoked. BUILDING FEE
Q CONSTRUCTION LENDING AGENCY I SEISMIC FEE
D z I hereby affirm that them is a construction lending agency for Ne performmtt of TOTAL: ELECTRIC ME
O the work for which this permit is iasued(Sec.3097,Civ.CJ
Lenders Name PLUMBING IEE
O U Leaders Address QTY. MECHANICALP R 1 FEB
V cenify that 1 have read this application And face Banthe above information is
�"' L2a convict.I.frent.cmnply with All city mMamot', lirw¢uandsum laws relningto PERMIT ISISUANCP MECHANICAL FIiE
f- building construction,and hereby authoria representtives ofthis city toenterupon the CONSTRUCTION'fAX
V .bare-memioned in pen,for inspection fam ones.
ALTER O D TO MECH.
(We)agree to save,indemnify And one,hamsleaa the City of Cupertino sgainn
Iiabilities,judgmems,cost And expenses which may in any way accmeagams[.said City skICHANDLING UNIT(1'0 I o'"CFM)
in consequence of the granting of this Permit.
AIR IIAN15LNG NIT VER 10,W CFM)
Signature of Applicarn Conrrctor Data EXH UST II CO PAID
HAZARDOUS MATERIALS DISCLOSURE 11 1 TO 100, TU�a Dom Receipt As
Will the applicant or future building occupant store or handle hazardous material
m defined by the Cupertino Municipal Code,Chapter 9.12,And the Health and Safety MEATI UNITE) .Rs1bU,( BTU) TOTAL:
Code,Session 23532(a)7 •NTILATION FA (SINGLE ID7
13 Ycs ❑No
Will thenpplicont tfuwrc huildingcecupant meeyviprtmm ordevicu whichemit
BO? R-COMP(31 1(XJ"BTU) ISSUANCE DATE
hauardous air contaminants as defined by the Buy Arvin Air Qualily Management BOILER- (OVER 100,000 BTU)
District?
El Yea ❑No NEW RFSIDGNTIAI.MECH.—SQ,FT.
1 have mad the hamrdour actions rc05,25533 under Chapter understand
of the
if the uil Health&orSafetycur Coda have
ate 25505,t itis and 25574. 1 undersmmf that
if Insbuildinge re nutmeats ynave Marmot,thetins myssuanceoila to notify the
Occupant al the requirements which must M met prior m issuance of.Certificate of
Occupancy, '
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE