26698 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO1- - LKEMICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 26698 O
BUILDING PROJECT IDENTIFICATION v o
BUILDING ADDRESS:
;/�u �' �N/'�,/ SANITARY NO. APPLICADONSUBMITTALDATE
IaVy l./ �l /WW(-� UNIT# LOTH
OWNERS NAME:� /� ��� ON CONTRACTOR'S NAME: LIC NO:
//,/,yJ _ ��r ,,([
NIC
CONTROL N
'•ARCHITECI'/ENGINEER: LIC NO: ADDRESS: ✓G JiG ❑
CONTACT: PHONE: BUILDING PERMIT INFO
���j _ QTY. ELECTRIC PERMIT FEE
NCJ�/ 77%C _ ` BLDG ELECT PLUMB MECH
PERMIT ISSUANCE �63� l71 iii 1X
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL i� JOB DESCRIPTION —/�
pyZ Thereby of
fDivisin 3 offlouinss ad professions
Cohn,
mmeaense with �O AVIC Wv^
til Op Section force and of Division 3 of Ne Business end Professions Cade,and my license is in ppNF.IS
FF6--y�y
License ClasseH¢tAlic.N 3y�?--ZLZ7T� 8 /1 UPT0200AMPS
6 L Date r4 gRCHITECT"S DE LARATIC NO By 201-IflfiO AMPS — --
ZOy2 OVER 1000 AMPS SQ.IT.FLOOR AREA 8/SQ.FT,
Q I understand m ons shot o used as public sec mis. �'M�tS�r
FS_EW SIGNS EL I
gqyyfd Licensed
5y. 6 n OWNF -BUIL EaD CLARATION SPECIAL I 00
PJO V 1 hereby aff that 1 am exempt from the Contractor's License law, Or the
following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.M
E1 which requires a pemd,to co rnmel,slier,improve,demolish,or repair any swnum
}� pnor to its issuance,alsorequites the offbeatfor such pemtiuo file a signed momentI
POWER E CFS
_ pK that he is licensed pursuant to the provisionsof the Contmctols License law(Chapter SWIMMING L ELECTRIC
d eLL 9(commencing with Section])00)of Division 3 ofthe Businessund Professions Cade) VALUATIIOOb
1-_y or that he is exempt therefrom and the basis for the alleged exemption.Any violation ofDUTLBf$-SWITCHES-FIXTURES 3 Z 00 D a
> $eClloa]dlLS by any applicant for aPermit subjects the applicator ncivil penalty of
Gnot roam than fve hondrcJ dollars($500).
m ❑ I,asownerofthepropm ,ormyomployesswith wages avtheirsalecompemation. NEW RESIDENTIAL ELLCI'R _SQ.FT. STORIES TYPECONSTRUCTION
wllido thework.aad the suuctum Isnot lntendedoroffered formic(SM.]094.Baslness
end Professions Code:The Contractor's License law does not apply to an owner of
properly whobuildsorimpmvnthemm.andwhodms such warkhimxlforthrough his
I(, OCC.GROUP RES.UNITS
employcen,provided thnuuchimprovement vre notimendcdnroffered faraele. d
however,the building or improvement is sold within one yenofcompletion,thommer. TOTAL: W
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ LmnwraroFthe property,em exdusivelyrenuecting with licen3ed contrntonto QTY' PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(SCC.7044,Business and Professions Code:)The Contractor's
Licenxl.owdoesnotapplytoanownerafpropenywhobuildsorimpmvestheteoqund PERMITISSUANCE
who mn0ums 4+rsuch Drnlecu withacontracun(s)licensed pursuant mthe Contrsctora ALTER-DRAIN&VENT.WATER IA
License Lew. (' ) FEE SUMMARY
❑ Ism exempt under Sec. ,pNF P C for this reason BACK FLOW PROTECT.DEVICE UTSIO
SANITARY Y N
Owne, n.... \ RECEIPT#
DRAINS-FLOOR,ROOT,AREA.GOND.
WORKMANCO ON DECLARATIOd SCHOOL TAX Y N_
❑ I bereby.ditrm that i have ace ate of conxntweelf-inauremeceniftcamaf / FIXTURES-PER IRAP .RECEIV #
Workers Cnmpensa[ionlnsur oreartifed copy thereof(Sce.38 ,LabCJwbich 17 �O PARK ME Y N
n ail emplo ' rthis permit GAS-EA.SYSTEM-1 INC.4OTLETS RECEIPT#
BUILDING DIVISION FEES
Company IF GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEF.
Certified copy is=OM�SATION
CeriOcd copy istion division. GRFASMNDUS]'RL WASTE INTERCEPTOR GRADING FEE
Jy
ON FROM WORKERS' GRLASLTRAP SOILS FEE
NSURANCE
or as.) on hecompleted ifthe Permit is hundred dollar($10t SEWER-SANITARY-STORM F.A.200FT. ENERGY FEE
Iceper(ortnan ew this permit isi ed,lshall WATER HEATER W/VCNT/ELECTR
no empin m any td�a�aR he�,object m t u Workers PAID
C Jamation Lawso alBemia, t WATER SYSTEMITREATING Date Receipt
O Z A pliant
zO NTICETOAPPLICANT:ILafar makin ane of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
orae subject the Workce.Co tion provisions ofthe Labor Cade,you must BUILDING FEE 0
t'
to hwith comply war ,ions or this permit shall be deemed revoked. 2Ia,
W [� CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that them is a commuctim lending agency for the performance of /
V O the work far which this Permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE Fro
r..s Lender's Name
[C�, PLUMBING FEE
0 Lenders ndare„ QTY. ". MECHANICAL PP.RMIT FEE dp
1 candy that 1 have rend this application and state that the move information is I
MECHANICAL PLC r ''.9
>. 0. correct.I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE `d
. Za OD J 2r
tIA building construction,a d hereby suthou nrepresenutivesof Nis city wenteruponthe CONSTRUCTION TAX
V Z move-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify end keep ha ntleo the City of Cupertino against
r.. liabilities,judgments,costs sndexpenses which may in any wayaceme against said City AIR HANDLING UNIT(TO 10,000 CFM)
X in con nee or mmingM isp mit /�
S7 " AIR HANDLING UNIT(OVER IBM)CFM)
5T'gnnureof Applicam/Contmctm Doe EXHAUSTHOOD(W/DUCI)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO Iffy"BTU) Date Receipt
Will the applicant or future building accupant store or handle hazardous material
as defined by the Cupernum Municipal Cale,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 (3
BTU) p TOTAL:
Code,Section 25532(q? 1rS CC 7S'oD
El Yea, 11 NO VENTILATION FAN(SINGLE RESID)
000 BTU)
(J� ISSUANCE DATE 71-29--
t/O
Will theepplicanmr(utum building oecuponmuequipmemordevices whichemit BOILER-COMP CHIP OR IOgpp C T
hazndom am
air contaminants as defined by the Bay Ares Air Quality Management BOILER-COMP(OVER 100,000 BTU) 1J�NN�+'k$ .M 4
District?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
1 have read the havudaus menumis rcquiremrnu under Chatter 6.95 of the JUL — 1994
Calimmin Health&Safety Coda Sections 25505.25533 and 25534.1 undersand that
if the building does not currently have a tenant,that it is my responsibility to notify the /s
occupant of the requirements which must be met prior to issuance of a Certificate of CI I I Ur vwrGp%J I44U
Occupancy. l
Owner or authonzed agent Doe TOTAL: .011 ISSUEDBY:
OFFICE