26463 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO M PERMIrrvo.
APPLICATION/PERMIT PLUMBING--MECHANICAL 26463
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 1.
BUILDING ADDRESS: SANITARY ND. APPE�R.] ONSUBMMITALDATE
UNIT# LOTH sEJX O/( 5/
O RSAMR: PHONE: CONTRACTOR'S NAME: LIC NO:
.�
D G O NIC CONTROL N
ARC CI'/ENG NEER: LIC NO: A DRESS: ❑
CONTACT PHONE: y BUILDING PERMIT INFO
QTY a,'j� ELECTRIC PERMIT FEE
1T,;. ^ '` BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ 0 El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DESCRIPTION
Q=Z Iherebyaffirm that l son limmedunderprovisiorsofChaprer9(commencingwith
POO Section 7")of Division 3 of the Business and Professions Code,and my licence is in PANELS �y
F-IIyy fullfmcewdeflect I r'
QUzW Littnu lass Lic.# cr UP TO 2M AMPS
y<dzm)ox Date Contractor 201-10MAMPS
Z FOy IF,, CHITECPSDECLARATION OVER 1000AMPS SQ.FT.FLOOR AREA $/SQ.ET.
OZ-0 1 understand my plans shell be used as public records. I jl n p
EEn, m SIGNS ELECTRICAL I� I I' J IN
u�'
R „'4j Licensed Professional
1�d G OWNER-BUILDER from
m the Cou TION SPECW.CIRCUff/MISC. ( I II^
W 3aL P' Ing mow nINmt that 1 am exempt from the Contractors License Law for Ne p
Om followingrtswn.ermit(Section
tocommuBusiness and Profession Code:My city structure TEMP.METER OR PoIR]NST. I
y; which rtyuircs a permit comtnd alter,improve,demolish,or repair any awctme (/
�.;!(Y� prior to its lssunnce,also rtqu'sees theepplicmtfm welt permitmfileesigrlW statement POWER DEVICES DATE-0
µcej
that he is licensed pumstanno the provisions of the Commust ors Lim rue Law(Chapter
dno� 9(commencing win Smtion]1100)of Division 3 ofthe Business and Rofasionacode) SWIMMING POOL ELECfRic --- VALUATION
yW or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWfI'CHES-FlX'NRES
1=4< Section 7031.5 by any applicatt for a permit subjects the applicant to a civil penalty of
nmmnrethanfive hundrtd dollar(f5no). NEWRFSIDP.NTIALELECIR _SQFT STORIES TYPE CONSTRUCTION
❑ I,mownernflhepropeny,ormyemploymswiNwa mmirwlecompenwtion,
y will dome work,and the structure isnot intended oroffemd formle(See.7044,Business
and Professions Code:The Contractors License Law does not apply to an ownx of
property whoboildam improves themou,end who dna such work himselfm through his UNITS
OCC GROUP RES.
it owncmployma,pmvidMthnsuchimprnvemenaarenotimmndedoroffemdforsale.If,
however,the buildingorimprovemcnt is sold within oneyemofcompletion,the owner- TOTAL:
builder will have Ne burden of proving that he did not build m improve for purpose of
sales).
❑ Lnowner ofine property.smendueively contacting withlicrosW crnractmam QTY] ' PLUMBING PERMIT FEE FLOOD ZONE "N
comtuct the project(Sec.7044,Business and Professions Cade:)The Commencer
LimwUwdmsnotapplytuanawnerofpmpenywhobuildsorimpmvathereon,atM PERMIT ISSUANCE 3� Chy
whocommcts forsuch projects withaconuactor(s)licensed pursuwtto the Contactors ALTER-DRAIN&VP.NT-WATER(FA)
License Law. FEE SUMMARY
❑ 1 em exempt under Sec. B&P C For Nis reason BACK FLOW PROTECT.DEVICE OUTSIDES
SANITARY Y N
Owner Dote RECEIPTp
• DRAINS-FLOOR,ROOF,AREA,GOND.
WORKMANCOMPENSAfcm=tQARATWN SCHOOL TAX Y N
�Iherebyaf0rmthin1hoveaoracerdieconsentoself-insure,maabC.)which
R[CEIPTp
Workers'Com FlXTURES-PER TRAP
prnsetioninsumnce ora ttniled copy thereof(Sm.3800,Lab CJ which PARK FEE Y N
Lute,all empl d t '• RECEIPT,
� GAS-EA.SYSTEM-I INC.40ILTLEI'S '
Policy N BUILDING DIVISION FEES
ComPwy •un / b ��` GAS-EA.SYSTEM-OVER 4(EA) PLANCHF.CK FEE
❑ CenirW copy is hereby famished.
Certified copy is filed with thecity inspection division. GREASEEANDUSTR,WASTE INTERCEPTOR GRADING PER.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS IEE
COMPENSATION INSURANCE
(ITissectianneed not becompleted tithe Fervor is forone hmtdreddollus(SIM) SEWER-SANITARY-STORM EA.20oFT. ENERGY FEE
or Jr..) q
Icertify that in the perftrrance of the work for which this permit is towed.I shall WATER HEATER W/VENT/ELECIR l OU
not employ any person in my manner an as in become subject to the Wuhers' PAID
Compensation Lawsof Catifomia. Data WATER SYSTEMTREATINO Date Rmeipt#
O z Applicant
z�+ 0 NOTICE TO APPLICANT,If,oftar making this Cemliote of Exemgion,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
t" C4 become Subject the Workers Compensation provisions ofthe Labor Cade,you must BUILDING FEE
�. > forthwith comply withsuch pmvioion m this permit shell be dmmed revoked.
W o CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1 hereby affirm that there is a construction lending agency for the performance of 00
the work far which this pmnit is issued(Sec.21(1)],Civ.C.) TOTAL: ' ELECTRIC FEE
Its p Lenders Name `-� PLUMBING FEE / �0
Q U larders Address II I MECHANICAL PERMIT FEE
W I cenify,Nm 1 have read this application sod sans that the above information is MECHANICAL FEE
correct.I agree to comply with all city and county ordinwca and turns laws relating m PERMIT ISSUANCE
hbuilding construction,and herebyauNndle repreunativaafthia city memerupon the CONSTRUCTION TAX
V7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
try• (We)agree uo wve,indemnify sod keep harmless the City of Cupertino against
'iebilitierjudgments,cmband expertes which may many way/o/cc//,9re augur twid Ciry AIR HANDLING UNIT(TO 10,000 CFM)
'ef of this permit �// ���� AIR HANDLING UNIT(OVER 10,"CFM)
Signamre of ApplicaMCrntractnr Dam EXHAUSTHOOD(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO Had,"BTU) Data Receipt#
Will the applicant or future building occupant stere or handle hearolous material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
II` Code.Section 25532m)T VENTILATION FAN(SINGLE RFSID)
❑Yes 25�vo
Will the applicanuorfuturebuilJingoceupwtuxequipmentnrdevica whichemit /�q
BOILER-COMP(RHP OR I00,0Uo BTU) ISSUANCE DATE
• humorous air contaminants as defined by the Bay Ara Air Quality Management BOILER-COMP(OVER Iffl,"BTU) Y" �d B
DisainsrT A jD
❑Ya Nr NEW RESIDENTIAL MECH. SQ.FT.
1 have read he has ndmi,materials requirements under Chapter 6.95 of the ��
California Health&Safety Code,Sections 25505,25533 end 25534.1 undersand that 9g
Hire building does not currently have atrnent that it is my resprmoibility to mffy,he C/�y a�
occupant of rhe req ire ems which must be met prim to iwuen of u enifirme of L¢ I,,-
an ��VAI
Owner or unmerited agent TOTAL: ISSUED BY:
OFFICE