26171 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO :DLNtrRLT:CTRl . FERMI r NO.
APPLICATION/PERMIT PLUMB NG-MECHANICAL.
If UILDING DIVISION BUILDING PROJECT IDDN'J'IFICA'I'DJN
!IPI-DING ADDRESS: SANITARY NO. AG
^PPLI9IDT I
N SCENT DATE
6'6 W 7 V UNIT# LOT# L�2
ql10NURSNAMG: PHON' C RACfOR:ti NAME: LIC NO
/W. r :
S JNIC CONTROL#
ARCIII'1'ECf/ENGINCER: LI O: A KESS: ❑
CONTACT: PHONE: - BUILDING PERMIT INTO
N QTY. ELECTRIC PERMIT _ FEE
BLDG ELECT PLUMB ECH
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
Metz throh,wr...nhw l am licensed underprnvisionsofCh,an9(wandancing withJOB DESCRIVI'ION
FJU6 SemiorceaddofDivision3afthe Business and Professions Code,and my license is in PANELS
pJ� Sectifall on 7").f
") ff«t.
FywLic Lic.# UP TO 200 AMPS
y<
a ate. Contractor 201-1000 AMPS -
20m7 ARCI IHT:CTS DECLARATION OVER I"AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O Z_C I understand my plans shall Ise used as public records.
F..y(=W .SIGNS ELELTRIGAL.
Q edJ Li«need Pmhaainnul
W W Q OWNER-esma from
DECLARATION SPECIAL CIRCUIT/MISC. .#t
y°20y V 1 hereby n. hot I am exempt from the Cosions Coa License Law for the
t, U ,
F LL O y following reason.(Section 1031.5,Rosiness and Professions Code:Any city......ty TEMP.METER OR POLE(NST.
_ I which requires a permit to construct.alter,improve,demolish,or repair any nrvetur,
µit�>� prior to its issuance,also requires the applicant for such peril to file a signed statement POWER DEVICES
O pthat he is licensed pursuant to the provisions of the Contractors License Law(Chapter
F
p-n,e4 9(wn.numcn,wlm 1,Scetioa 9000)of Division 311 Buaineasund Professions Code) SWIMMING POOL ELECTRIC Q,(., VALUATION
yYj_y arthro 7033. byananat applicant
frefrom an(]the basisfor
subjects
the exemption.Any violm violation OUTLETS-SWITCHES-FIXTURES
H'ZQ Section T03L5 five
anyapplicantforaperil subjmathe applicantmecivil penalty of I 7
no,mom than five hundred dollen(3500).
O NEW RESIDENTIAL ELGCIR S .FT.
W
❑ I,aaowneroftheprapeny,ormycmplmy«xwith wagesmtheicsolecomp Business Q STORIES TYPE.CONS'BUCT'ION '
y 3� will dmho wous C d e:The Contractors
Lid an,Law does not
apply 9044,Business
property
rA Professions Code:The Conrtimrs nd mss Law dos mol apply lf rt owner iof
s
whodoxot
ownemwyces,pmvidedprtsuoves Ihimpmvadentsumnsuch workoraffmdfor e.If,
employebuildigori improvement
fooplettired for owder- OCC GROUP RES.UNITS
however.ulderwthe building or improvement is sold within one year of rompleeifor the pose of
huedcr will have the burden of pnrvirig that he did not build or Improve for purpose of TOTAL:
sal
❑ Lmownerotthe pmpenY.amexewsively convecting wilhlicensed commetorsm QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
rampart the project(Sec.7(34,Business and Professions Code:)The Contractor's
License Lawdoes not apply man nwnerofpruiprty who builds or improvesthereon,and PERMIT ISSUANCE.
who contracts forsuch projects with o eontmemgs)licensed pursuant to the Contractors ALTP.R-BRAIN&VPNT-WATER LA FEE SUMMARY
Llceme Use. (' ) r
❑ I am exempt under Sec. ,B&P C for this masan BACK FLOW PROTECT.DEVICE I ft,41k
Owner Date
RAT DRAINS-FLUOR.ROOF,AREA,COND. REC I
WORKMANCOMPfimwof COMPENSATION DECLARATION SCHO X R Int
-covers❑ Ihercby affrthatlhnveacertifam of consenno self-insure.orecertifcem of v / i' RE E
FIXTURES-PER TRAP
)Workers Cmployee'ionler thisermit. ificd wpy lhererf(S«.3,00,LnbCJ which I PARK FIiE
all employee's under this peril.
# GAS-EA.SYSTEM-I INC.4 OUTLETS
S
Palh'Y +i
°ny GAS-13A.SYSTEM-OV MT 4(EA) PLANCI IECK FEI:
Certified copy is hereby famished.
Cdnifed copy is filed with dirtily inspection division. GREASE/INDUSTRI.WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS MEF.
COMPENSATION INSURANCE
Mis section need not be completed iOhe permit is forms hundred dollen(SIND) SEWER-SANITARY-S'T'ORM EA.200FT. EhIERGY FEE
whets.)
T certify that in the performance ofthe work for which this permit is issued.)shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to became subject to the Worker% PAID
Comtudiewma Lawaof Celifomla. Date WATER SYSTENUTREATING Dom Receipt#
O C) Applicant
Z 0 NOTICE-1.0 APPLICANT:If,aftermotor,this Cenificateef Exemption.you should NEW RESIDENTIAL PLMIL SQ.PT, TOTAL:
become subject to the Worker's Compensation provisions of the Labor Code,you must
forthwith comply with such provisions m this permit shall N,deemed revoker. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a z Iherchy affirm that Nerd iso dorouuction lending agency far be perfnrenctiof TOTAL: ELECTRIC FEE
V O the weak for which this permit is issued(Sec.309].Civ.C.)
Lenders Name
w0 U Lender's Address - QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I renify that 1 haver road this eP,lanumn and matltbat Ibe above information is
Tut 1 correct I agree,to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
building contraction,and hereby authorize representatives ofthisciry to enter upon the
L) z above-mentioned property for instated.purpose, ALTERORADDTOMECII. CONSTRUCTION TAX
(We)agree nudcad east,indemnity keep hat leas Ne .ity of Cupertino ngulnst
IiaFilitica,jg maOnsanI scswhich yinan ay
occmeegainsls ACity AIR HANDLING UNIT CFO 10,000 CFM)
In mnuqu<nc f the gr f u pmmit. 1
AIR HANDLING UNIT(OVER 10,171(a)CFM)
LDoe EXHAUST'HOOD(WB)UCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE BEATING UNIT(TO IftWill BTU) Date Receipt#
t
/n!e""'t"heNhend.1future building occupant stem or handle hazardom mmdalf1EATING UNIT(OVIiR I(q,f1IX1 BTU) TOTALythe Cupertino Municipal CWe,Chapter 9.12,and the Health Ind Safetyon 25532(n)P
❑Yes ❑No VENTILATION FAN(SINGLE RFSID)
Will Ibe applicant in future building«cupum use equipnmm nrdevicea which emit
BOILER-COMP(3HP OR IN."BTU) ISSUANCE DATE
haznrdnus uit mntwainants m deriard by mo Buy Area Air Quality Mamtgement BOILER-COMP(OVFR D%I,WO RTU)
�: t, PA � q
roc ❑Yes ❑No NEW RISIDENTIAI.MECH. SQ.Ff. M 4m
1 have mad the hazardous materials requirements under Chapter 6.95 of the RAR
(�.d
Culilbrnin llealtM1&Safety Code,Sections 255115,25533 and 25534. landevand that �'Ihl�l�AR 111 7 Q
if the building dues not currently have a meant that it is my restorwihility m notify the I
cepaml of the requirements which most Is,met prior to issuance of a Cenifcme of
Occupancy qI► u
V
Owner onmmhorizcA mmgcm Data IOTA ISSUED BY:
Q OFFIC