26276 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IJUILm .-LI,HCTKI AI, PERMIT NO.
APPLICATION/PERMIT PLUMB{NG-MFIDENTI ICA 26276 6 2 7 6
BUILDING OF
DIVISION I{IlI1.U1NGPROG-M MECHANICAL
L L
BUILDING ADDRESS: I /` 1 Nh� SANITARY NO. APPLICA'HOONSSUBMITTAL DATE
IUi3 W
3 al J— i e C YL LOT#
OWNERS pyA1F:: PHONE: CONT Ct R'S NAM': .IC NO:
OWN CONTROLp
RCHITECT/ENGINIileR: LIC NO: ADDRESS: ❑
IWA
CONTACT: PHONE: BUILDING PERMIT INFO
�II04%0QT'Y. ELECTRIC PERMIT FEE
NLUG Ii1.ECT PLUMB MECH
PERMIT ISSUANCE •{
�
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL Y�
my.Z I hereby action that l am licensed underpomycionsofaipwr9(commenciagwith IOFB DFySC.RIPHON
PiCq Section 9W0)ofDivision 3 of the Business and Professions Code.and my license is in PANELS ���'
c F. ^1 L
FZw License Clas p 8��ey11P TO 200 AMPS
rq Q x0 Omc�-Contractor
2(11-I IXq AMPS
F- x0
ARCfI1TECI'S DECLARATION SQ.FC FLUOR AREA $/SQ.F1'.
ZOy�- I understand my plan%shall be used as public records. OVER Ig81AMPS
OZ O
SIGNS fiLliC'IRICAI.
Q Licensed Prefcsxiomd
�KQ OWNER-tlUIhDER DECLARATION SPECIAL CIRCUIT/MISC.
kOd V I hereby off.that 1 um exempt fresh ,be Comm�or's License Law for Ne
W3ay following reason.(Section0031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
R: which rectums a permit m cnnatmc,,altar.improve,demolish,or repair any druame
cal to its issuance.also the imm for such nolle a signedstatement POWER DEVICES
pour quirts pp Permit
C C M O Nal he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
iiofl� 9(commencing with Section?000)of Division 3 of the Business and Professions Code) SWIMMI VALUATION
W=ro m Nal he is exempt herefrom and the basis for the allegW exemption.Any violation of �`—O
FZaSection 7031.5 by any applicant for a Permit subjects Ne applicant to a civil penalty of OVI'LEI' r$WITCIIES=F1%TUREJS W
not more than Eve hundred d.U.($500). 0
f�M NEW RTS IAI:FLE611 Q STORIES TYPECONSTRUCTION
,at ❑ I,asownerof Nepr^peny,ormyemploymswiNwagesu Neirsoleenmamodon,
d3— will do the work,and the structure is not imenAWoroffered frrsale(See.7uwd,Business
and Professions Calc:The Commnors License law does net apply to an owner of DATE
owincrsywyces. improvach improvements
mprovdoe esuchwmk M1imsanedforugh his OCC.GROUP RFS.UNITS
howemployees.Providedgri Nat suchmement is
thinore imendedoroffered for sale.If,
however,Neavet a burden
of improvement issolde didnot yearor improve foron.Neowner- TOTAL:
builder will have the burden of proving that he did not build or improve far purpose of
sale.). QTY. PLUMBING PERMIT FEE ZONE
❑ I.asowner^fthe property,amexclusively communing with licensed conouemnm _ZONEAPN
constua the project(Sec.7044.Business end Professions Code:)The Contractor's
License Luw Ates not apply to un owncrof propcny whobuildsmimproves thereon,and PERMITISSUANCE
who contracts for such projects with acomrenobs)licensed pursuantmtheciormc or's
License Law, ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I um nxumpt under Sec. ,B&P C for this rcnson OUTSIDE FEES
BACK PLOW PROTECT.DEVICE
SANITARY Y N
Owner Dam DRAINS-FLOOR,ROOF.AREA,COND. RECEIPTM
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ Iherchy o(Enn lhatlhuve aceni0cate mf emnxm mttlf-insure,oro certificate of FI%TUNIS-PER TRAP RFCEI
W.Hers'Compinedi^nl^sumnceoro ccnifiMn,,Y tberesof(Sec.38W.Lab C.)which PARK ITE Y
err all employee's under this permit. !3a I
GAS-ESYS'D9M-I INC.4OUTLETS BU 1 IV
A. ION S
Policy M
Company GAS.IN.SYSTEM-OVER 4(EA) PLANCHECK FEF.
❑ CeaiEW copy is lmrehy famished. AL Y
❑ CcniOW arPy is fled with the ci,y inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFSSETRAP SOILSp
COMPENSATION INSURANCE
(This section need not becompleW ifthe Permit is for one hundrtddollars($100) SEWER-SANITARY-STORM EA.200FT. RNERC
NWV
or less.)
I certify that in the pscrfmmwec of Ne work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ any perm. in any manner sc as m baome subjxt m the Workers' 1
Af Compensation Wweof California. Dam WATER SYSTEM/TREATING 1.7qRcceiptp
O Z Applicant
z � NOTICE.TOAPPLICANT:if,after makingthi,CmifimmofExemption,you should NEWRESIDENIALPLMB.—SQ.p. TOTAL:
I-" y become subject m the Worker's Compensation provixio:nofthe labor Code,you must BUILDING FEE
� > forthwith comply with suchpromeimus orchis Permit shall be deemW revoked.
W Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
I bercy a
bffirm n NHere is a congm,den lending agency for the performance of
U O TOTAL GLIiCI'RIC FEE
the work for which this permit I,issued(Scc.309],Civ.C.)
Leader s Name PLUMBING PB.
I,
F" Lender's Address QTY. MECHANICAL PERMIT FEE
U I eenify that I Iwve mai this upplicuum and state that the above infomunion is MHCHANICAITE
>" W cored.Iagraincemply with all city and county oninoures and state laws relatinge, PERMIT ISSUANCE
(• building construction,and hereby enthrone,representatives ofthiscity to enter upon the CONS'1'RUCI'10 TAX
U z alxwe-mentinncd prop
property for inspection purpose. ALTER OR ADD TO MECH.
(Wc)agree m sat damnify and keep harmless the City of Cupertino again,,
liubili,ies,judgnem: and expcnus which may in any way eccme against said City AIR HANDLING ON IT(TO 10,00)CFM)
AIR HANDLING UNIT(OVER 10,000 CFM)
tents of
8mnling of Nis pcmni
g u PlivmVC.ntmetar Data EXHAUST HOOD(WNUCD PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BT1p Date Receipt
Will the applicant or furore bu' ng ottupant stmt or handle hazardous material IIEATING UNIT(OVER 100,000 BTU) TOTAL:
a,defined by the Cupertino Mu rpol Cade.C Ilt:1 9.12,and the Health and Safety
Code,Section 25532(a)? r VENTILATION FAN(SINGLE RMID)
❑Yes No
Will Ne applianmrfumre buil ' gmcupantuxryuipmemmdeviceswhichemit
BOILER-COMP LBIP OR IM."BTU) ISSUANCE D
10 ez docs air comamina is as fined by he Bay Area Air Quality Management BOILER-COMP(OVER 100.000 BTU)
)iarin? ❑ A I DYee No NEW RESIDENTIAL MECH. FT. V-P fi
1 have most the hazardous materials requirements under ChVier 6.95 of the
Calilbrniullealth&Safny Codc.Scdioms25505,25533and25534. linlmtandthn MAY 27 1994
it,he building Aocs not currently have a emmt,that i,i.a my responsibility m notify the
occupant of the or,...cannot,which moa be in prior to issuance of a Cenificum of
Occupancy.
"I Ise w l
Owner or uuthoriroJ agent Dam TOTAL: ISSUED
OFFICE OV