26318 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINTPEN ONLYRu A PI:KnfIT NO.
CITY OF CUPERTINO PLUMBING-MECHANICAL 2631L,
BUILDING DIVISION APPLICATION/PERMIT ,f " _ BUH.mans,c crmeNrurlCenoN,,a=-r r
SANITARY NO. APPLICATION SUBMITTAL DATE.
BUILDING ADDRESS:
Q t / UNITN LOTH
WNERS NAME: Pq &
CONTKr}C'I'OR'S NAM : • AND 447
NICCONTk .F
J !Q Af CL
CHITECT/ENGINEM: LIC NO: 5: �� —
A17 C ❑
/ O �I/JUT S I 1
ON"TACT: PHONE: BUILDING PERMITINFO'2=-
CPE 4
✓. . BLDG ELECT PLUMB Mhuss
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES.RESIDENTIAL JOB DESCRIPTION
_Osz I hereby affirm that l am licensed under provisions of Chapter 9(commencing with
:00 Section 7",of Division 3 of she Business and Profwinal Code.and my license is in PANELS
full forte and effcc UP TO 200 AMPS
.Z._
License C Lic.N
v<Oi v Date _ _ Comracio� 201.1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
Z ARCHffECTS DECLARA ON OVER 10110 AMPS
t!� 1 understand my plans shall his,used in public records.
SIGNS ELECTRICAL
;EJLicensed Professional SPECIAL CIRCUR/MISC.
:56 OWNER-BUILDER DECLARATION
`/ I hereby affirm that 1 am exempt from the Contractors Linnen law fm Ne
c O< following...(Section 7031.5.Business and Pmfwions Code:Any city m county TEMP.METER OR POLE INST.
which requites a permit te eortswct alter.improve.doundlah,to capstan any machine POWER DEVICES r
pnormiu issuantt.A.,opuires she applicent forauchpead tofileasignedswement T
�p Nat he is licensed punuanno the provisions of the COnanors Littnu law lChaNm SWIMMING POOL ELECTRIC _ - ./ ALUATION
;MY 9lwmancing with Section]0001 of Division3of the Businw and Profenions Code) _
_y tbasic ellcgedampin. Yvioladon of
Or that he is exempt sh"froand MSWITCHES - (Mani ��
.KQ Section 7031.5hyany applicant Into permitsubjectatheappliand Macivil ptmalry Of - -J �' �I j
-_, Out me thn five handout dollus($500). NEW RESIDENTIAL ELECIR !SQ.FT. ORIES PE CONSTR =0
.3
❑ I.uownerafthe property.ormycmploymwishwegesssthcirwlecomprnsation, Q
will do she work,andNe aactus is not intended oroffesd formic(Sec.7044,Business hIC `
and Professions Cods:The Crimean,s License law does not apply to an owner Of
propem who builds or improves thereon.and who does such work hiaelfor through his OCC.GROUP RES.UNITS
owneva.oebuilr idW thatsveh iiswldwiuinn imendcd letio,feo
however.thebuildmgmimprovenunt is wld within oruYwafeompletian,Neowncr- TOTAL:
Wilda will have the burden of proving that he did not build or improve fm purpme of _ _ - "„ .f,.r�:,.N
We.).
'S,,PLUMBING PERMITS FLOOD ZONE APN
❑ Laownerofthe Property.amexdusivelycontracting withlicensed wnmcmnhi Q •6..:5t,}p,,,-m.,- n vv ✓'iN+
connotes the project(Sas 7(44.Business and Profusions Code:)The Laminators PERMIT ISSUANCE
License law doesnotapplytoanmaria.f Property,who builds.,improve;thereon,and
uMcm=ufmsuehpmjcctswiNaeanvaetor(s)Iicrnsed Pursuantto Ne Conaetor's ALTER-DRAIN!&VENT-WATER(EA) - FEESUMM_ARY,T-,'�j.
Baan.law. T
❑ I am exampt under Soo ,B&P C for this Tenon BACK FLOW PROTECT.DEVICE SANITARY Y_N
RECE P N
Owner Data DRAINS-FLOOR,ROOF.AREA.COND. SCHOOLTAX Y_N__
WORKMAN COMPENSATION DECLARATION RECEIIT a
❑ Ihenebyaffirtnthetlhaveacenificas of consort maclf-insure.macertifute of FIXTURES-PER TRAP PARK FEE Y_N__
Workers Cmnpcnsation Insurance ora artifial copy thereof(Ses.3800,Lab C.)which RELTIPT N
van all employees under this permit. ag 3 ' GAS-EA.SYSTEM-I INC.40UItEfS BUILDING DIVISION FEES
Polies M V
Companyd.A� GAS-EA.SYSTEM-0\'FM4fEA) PLANCHECK FEE
,❑J Certified copy is hereby famished.
I.y Csnified copy is filed with the airy inspection division GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION BNSURANCE
(This section e need meW completed ifshpermit is for onehundred dollars(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
Or less.)
I amity that in the performance of the work fm which this pewit is aided.I shall WATER HEATER W/\TNTIE.ECTR PAID
not employ any person in any manner so as to become subject in the Workers WATER SYSTEM/TREATING Date Receipt N
Z Companationlawsof California. Dam
Applicant NEWRESIDENTIALPLMB. SQ.FT. TOTAL:
O NOTICE TO APPLICANT:if.after making this Catifcam of Eamption.you should
become subject to the WorkersComperrmtion provisions Of the Labor Cade,you must BUILDING FEE
f v ywidt comply with such provis amo or Nis permit shall be decm>d revoked.
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
j Z I hereby efforts that there is a construction lending agency for the Performance of TOTAL ELECTRIC FEE
/ C) Ne with for which this .it is issued(Sec.3091,Civ.C.) - _ ,.r
Lender's Name a', `s`..",. it.45�•,•-} ''" ti'4,. PLUMBING FEE
F Lender's Address =MECHANICAL PEAMTT'e'-..'^ak' "�E.i,>
' cO 1 tally that I have read this application and state that the above information is x" MECHANICAL FEE
6. tract.I agree to comply wish all city and county ordinances and sum laws slating to PERMIT ISSUANCE
In building construction.andhereby nthodrs"praumniives ofthiscity to enter upon he CONSTRUCTION TAX
! Z above-mentioned propeny for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save indemnify and keep hear ss the City of Cannons againn AIR HANDLING UNIT(TO 10.OW CFM)liabilaies,judgmenu,costs and expenses which may in any way same against said City
in consequence of the Shooting of this Permit. AIR HANDLING UNIT(OVER 10.000 CFM)
Signams of APPlicanVConanor Das EXHAUST HOOD(W/DUC) PAID
Dau Receipt
HAZARDOUS MATERIALS DISCLOSURE 00
HEATING UNIT(TO 100.0BTU) N
Will the the Cuanrtino Municipal
unbuildi Code,ChOccupant apter
o,handle hHalth anddown aerial HEATING UNIT(OVER 100.000 BTU)
ns deOnW by the Cupertino Municipal Code,CTapsr 9.12,and the Health and Safety
Code.Section 255321p? .a VENTILATION FAN(SINGLE RESID)
❑Yes NNo ISSUANCE DATE
Will air contaminants
sis building by thentuse equipment Quality
eswhich emit
BORER.COMP(3HP OR 100,0)0 BTU)
nazardous air contaminants ns defined by the Bay Arta Air Quality Managemem BOILER.COMP(OVER 100,000 BTU)
Dismiss?
❑Yes No NEW RESIDFNfIAL MECH. SQ.FT. SCI,g 29 1994
1 have read the hazardous materials respimmoents ands Chapter 6.95 of Ne SEP
California Health&Safety Cade.Sections 25505.25533 and 25534. 1 understand that
if the building does act cumntIv have a tchant,that it is my responsibility to notify the1110
Occupant
Occupant of the maps nu which must be met From to Is c of a CmiGrate of
Occup _
Owac, rawhunre agent Dam TA ISSUED BY:
OFFICE