26536 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINOB H.uf�-h.LLFRI AL PGRMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 26536.
BUILDING DIVISION BUDAHN0 PROJECT IDENTIFICATION
BUILDING ADDRESS: '' 11 SANITARY NO. APPLICATION SUBMITTAL DATE:
r N UNIT Is LOT# �
OWNER'NAME. r PITO E: CONTRACTOR'S NAME?: LIC NO:
r /1 N/C CONTROL.#
• (z -i 5 L OL` 1' Zzo- I87-
ARGIII'1IiCT/IiNGINEIiR: LIC O: IL ESS:
TC a:_ 351 Q61j . / ' sHyJI*k,,r4c � �ItlL^ <7
CONTACT: PHONE: 1 BUILDING PERMIT INFO
I �S #7 �J / QTY. ELECTRIC PERMIT FEE
L 'Y s Arz—�v yQfj-?�6" ,o4 PERMITISSUANCE �1.� �' EL� PLUMB MECIt
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL 7� JOBDES RIPf10N
mc"Z Iherebyaf6rmtha11omlicensWunderpmvisiomofCapler9(commcncingwiih
PJ00 Sretian 70111 Division 3 of the Business and Professions Code.and my license is In PANELS
tFq-V E full force and effect'_,-T �y
F License Cla La !re • Lie.# ZZC S l+ver UP TO 200 AMPS ✓���
W
C.nlrealnr 201-1000 AMPS
Ft' AHCI IITECTS DECL RATION SQ.FI'.FLOOR ABPA S/SQ.PT.
Z O y OVER 1000 AMPS
02.'0 d o�9dory pl ha pub/Is'�(rtco
IL �Jf -�� ,aG2Z SIGNS ELECTRICAL
crtcsb( ston.l
OWNBR-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
0.E Noil!.1 hereby oilithat I um exempt m t frothe Commences License Law for the
tn following reason.(Section 7031.5,Business and Professions Code:Any city or county '1EMP.METER OR POLE INST.
(:
g which requires a permit to consumer.alter,improve,demolish,or repair any structure
MnM prion.its ismicand..h.neiitesthe.)plica,fofsuch permits.file.signednmemenl POWER DEVICES
W�'p0 that he is licensed purmanrto the provisions ofthe Connector's License Law(Chapter
0. do 9(commencing with Section 711(0)of Division 3 ofthe Business and Professions Cale) SWIMMING POOL ELECTRIC VALUATION
Ax
ordathe is exempt conform and the basis for the alleged exemption.Any violation.( OUTLETS-SWITCIIFS-FIXTURfiS
6 Section 7031.5 by any applicant for a permit subjects the oppticanuo a civil penally of 20/ (apo
_p not more than five hundred dollars(5500). NEWRESIDENTIALELECTR _SQ.FT. STORIES TYPECONSTRUCfION
❑ I,as.wnerofthe Dmpeny,ormyemployeeswith wagerer theirsolecompegsatite,
and Professions
andtheswcon isnotimendese La a does not
to an Business
and profess ns Code:The Connector's License Law does or apply to an owner of
ownemyloye u,pmvi improvesthimpmvnmentsH muttssuch wdedor ffemdlhrougM1 his OCC.GROUP RES.UNITS
employees,providedt,romhimprovementsin ne,aa demopleercd fficow. T-
however.@e building or improvement is sold within one year of completion,Ne owner-
ble.). will have the burden of proving that he did not build or improve for purpose.(
❑ I,mnwner ofthe propcny,amexclmively convecting with licensedrnntracmam Qom' PLUMPING PERM 11' FEE FLOODZONE APN
construct the project(Sea 70,14,Business and Professions Calc:)The Contractor's
License Law d.esnot apply o on ownerol ,,,p o,rhobuildsorimpmves,lereon,end r: rr gUANCIi
who contracts for such projects with a conwcom s)licensed punuanuo the Conttacor's
License lar. R DM M-WATER(EA) FEE SUMMARY
❑ 1 um exempt under Sec. ,B&P C far this rtmnn BACKqTAEP07ECT.DEVICE SANITARYOUTY SIDE I N
Owner Dam RECHIPr#
WORKMAN COMPENSATION DECLARATION DRAT -FL00 F,AREA,COND. SCHOOL TAX Y
El herebyaffirm that l have a certificate ofemsent tosel6insme,macamncate of Fl%TL FS-PC RECIi1P1'p
Wmkers'Compensation lnsumnce.racenifiedcopy Naze.((Sec.3800.Iab CJ which PARK EEE .CLI # N
covers Policy all employee's under Nis pertnit. '-t;.. / �f i p _EA.SYSTEM-I INCA OUTLE S
V/T L l 1 BUVQINGDIV IONFEE
Company j% - n /. -P, .SYSTEM-OVER4(EA) PLANCHECK °P. O
C3Cerfi ied copy i,limo by fumished.
AJ
❑ Cenifiul copy is filed with the city inspection division. GR. S T WASTE INTERCEPTOR ORVING it, -11113
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE S L FEF.
COMPENSATION INSURANCE
(This section need not be completed lfthe permit is Future hundred dollars 1$100) SEWL'R-S -S ORM BA.200FT. 11 B
or I—)
I certify that in the performance of the work for which this permit is issued,l shall WATER IT F. CIRkJ
not employ any person in any manner so u o becume subject o the Workers PAID
Compensation Lawsof Califomia. Date WATER SYS ate Rccciptp
Q z Applicant
z 0 NOTICETO APPLICANT:If,after making this Certificate of Exemption,youshould NE•WRESIDENTIALPLM. SQ.PT. 'TOTAL:
Z) becomes object to the Worker's Cnmpensmmr provisions M the Labor Code....must
s'•' forthwith comply with such provisions or this permit shell he deemed invoked. BUILDIN PER
Q CONSTRUCTION LENDING AGENCY als, SEISMIC .e a,—
Z I hereby affirm that there is a construction lending agency for the performance of ELECTRIC EE
U Or the work for which this permi t is irmed(Sce,3097,Co.C.)
Lia F' Lenders Name PLUMBING 'ET:
Lenders Address QTY. MECHANICAL-PERMIT FEE
U I Certify that I have mad this Wrestled and came that the above information is
const lu agree tocorn I thalln and Ninaaca and state laws relatin to PERMIT ISSUANCE
MECNANICAf E
e Py wi city y. g
U h m?,i,ngcanswctira end hcrcbspectonzerepmsentativesof this city.enter uprn the CONSTRJCTIO TAX
U 7 above-me)iuncd propve,indemnify
inspecting purposes. ALTER OR ADD TO MECH.
r� (We)agree 10 save,indemnify and keep harmless the City of Cupanino against
liabililics,judgments,costs andexpensea which may in any way ecrneegeinnnid City AIR HANDLING UNIT(TO 10,00(1 CFM)
in co if the granting of is pemyt. Q
/icl'''/rL�(/.I1— AIR HANDLING UNIT(OVER IO,OW CFM1
/ r EXHAUSTHOOD(W/DUCI)
Si,ewre of ApplicanUQmtmcor Deo PAID ,
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I00()00 BTU) Date Receipt#
Will the applicant or future budding mcupant more or handle hazardous material HEATING UNIT(OVER 100,(100 BTU) TOTAL:
as defined by the Cupertino Mu 'pal Code,Chapter 9.12,end the Health and Safety
Coda Section 25532(a7? M.
VENTILATION PAN(SINGLE RESIDE
❑Yes L�'I Nn q J ,yUpp(�1�RATE
Willthett,liescromfmum buildingoccupamoxeg.ipmem ordeviceswhich emit BOILER-COMP QHP OR 100,000 BTU) AR �� lllOf�
hwnrdoux air c.maminanle in d Brad by the Bay Arca Air Quality Management BOILER-COMP(OVER 101LOW BTN 1JJJJV
District?
� �S III
VI' wa,r k,IuurV
❑Yee �""" NEW RESIDENTIAL MECH. SQ.FT.
I have read the hazardous muteri.ls requirements under Chapter 6.95 of the
California building
do&ofSafelycur Code,Sections 25505,25533 and 25534.1 ity I.pond that V
if the building fires not currently have a o t that it is my possibility m notify the
.sets of the uirt nts whicp mu N m[ep{rW,to issuance 01 a¢etdf¢me.f
o.. 4 y. , l/ ✓W.7L 7/0'i ike
Owner to authorized agent Data ISSUED BY:
OFFICE