26579 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINODINT-FIEc'rRTcz PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 2 6 5 7 9
BUILDING DIVISION IIUILUIN(:PROJFIC'I'IDEN'TIF'ICATION
BUILDING ADDRESS PI — T// /w SANITARY NO. APAP/PLICATION SUBMITTAL DATE
UNLIT## LOT#
OWNERS NAME: PHONE CONTHACTOR'g NAME: LIC NO: lD
/� NIC CONTROL.#
•ARCHITECTANGINEh: LICNO: ADDRESS: `7 ❑
`n-1 CALOWhCA AUC PAW MI
CONTACT: /4(J ONE: BUILDING PERMIT INFO
�I KG C �/) QTY. ELECTRICPERMITHEC
ATI,
BLgG ELEQ PLOF M CE I{
(( Ay� ` PERMIT ISSUANCE 2.� V�jf- �1YC77Sa{ FLJ IT fLJ�J(\
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
pyz Iherebyaffirm loot l am licemadmenr pre,mavaofCTaptar9(conomania,with
�s100 Section Rl00)of Division 3ofthe Business and Pmfessiona Galland my license is in PANELS -w
Fy�' full force end eff t !^ 7L /�
(u�' Licenu Clu Lic.# 7 UP T0200 AMPS
sa 6 Ae Dzio� ate Coronation I 201-1000 AMPS
,z FON 7, CHITECTSDECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
1 understand my plans shell he used as public records.
ry
v
SIGNS ELECTRICAL
OZ—
�y�d Licensed Professional
y OWNER-BUILDER exeILDERm the Ca DECLARATION SPECIAL CIRCUIT/MISC. (!pr s .....//Aff..
W Ca!V 1 hereby uffrn the 1 am exempt from the Convector's License low for the l 7 Z� -/•/—'
W aOm following reason.(Section?031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE MST.
which requires a permit to construct,Wer,improve.demolish,or repair any structure
Y
� prorits N,mmce,alsorequirestheupplicantormehpximd,1.file.digmalwalemat POWER DEVICES
M0 pz that he is licensed pursuant to the provisions of the Comment's License Law(Chapter
R' oLL 9(commencing with Section?0am)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
y(_y or that he is exempt therefrom and the basis for Nealleged exemption.Any switalonof FIXTURES SWITCHES- - L,I 1 3
�ZY
Section 7031.5 by any applicant for a Permit subjects the applicant m a civil Penalty of OUTLETS- ' L
55yy� not more then rise handled dollars($500).
a'Fp ❑ I,axownerofthepropcny,mmyemployees wishwagumtheiraolecomPasodon, NEW RESIDENTIAL ELECIR IMSQ.FT. 7 STORIES TYPE CONSTRUCTION
a 5:�2 will do the wart,and the structure is not intended or offered for sale(See,?044,Business
and Profess ons Code:The Connector's License Law does not apply to an owner of
pmPerty who builds or improves thereon,and who docs such work himselfor through Na OCC.GROUP RES.UNITS
wnemplo ms,providedrharsuchimprovememsarenotintendedorofferedforsale.If,
however.the building or improvement is sold within one year ofeempletion,theowner- TOTAL: ,-7
builder will have the burden of proving that he did not build or improve far purpose of
sale.).
[3I,ua owneruf the property,erre exduaivdycnntncting with licensed contrvdon to QT' PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7044,Business and Professions Code:)The Can..&.
License law does nor plym an ownerofpropeny whobuildsmm,owa damear,and PERMIT ISSUANCE Z
whoconvarm forsuch projects with a contmctot(q licensed pursuanttothe Contractor's gL'IER-DRAIN&VENT-WATER(FA) FBF.SUMMARY
License Law.
❑ 1 am exempt under S«. ,B&P C for thioreason D: .'S
BACK FLOW PROTECT.DEVICE SANITARY YN
Owner Dete DRAINS-Fl.pOR,ROOFAREAGONDRECEIPT#
WORKMAN COMPENSATION DECLARATION . , . SCHOOLTAX Y N
❑ I hereby assure tint l have.ceniftmmif moment msel Lnusawn.m.cenifscateof FIXTURES-PER TRAP RECEIPT#
Makers'Campensmion Insurance Orn mrtified copy therccof(Sa.38o0,Lab CJ which PARK FEE Y N
covers.11 cmployee'a under this permit GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPIl
Policy# BUILDING DIVISION FEES
Company GAS-FA.SYSTEMAVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GRRASHUNDUSTRLWASTE INTI3RCEPL'OR GRADING FEE I Li2 s
CERTIFICATE OF EXF,MPIFON FROM WORKERS' GREASETRAP SOIhsphm LO 199• v�
COMPENSATION INSURANCE
(TN,seenonaeed act be completedENe permit isfor one hundred dollars($IN) SEWER-SANITARY-STORM FA.200FT. ENERGY FEE S
min".)
I carify rhe in the perfertnanro ofshe work for which this permit is issued.I she] WATER HFATFA W/VGT/ELECTR
not employ any person in any manner an as in become subject to the Workers' PAID
Compntseimlawsof Califarm, Date WATER SYSTEMf REATING Dam Receipt#
Q z ApplicantFIs♦ �ss7
Z0 NOTICE TO APPLICANT:If after making this Conduction of Exemption,you should NEW RESIDENT IAL I'LMH./N'1 SQ.FT. s /O TOTAL:
Tq beccmesubjectto the Woriels Compensower provisions ofthe labor Code,you mull �s-I
forthwith comply wish such provisions or this permit shall be deemed revoked. BUILDING FEE. 9&6XD
Q
0.
CONSTRUCTION LENDING AGENCY SEISMICFEE
I hereby affirm that there is a construction lending agency for the Performance of ,1
z TOTAL: l � CLF,CTRIC FEE I ��
U O theec
work for which this permit is issued(S .3(197,Cin CJ
Lender's Name PLUMBING FEE
LendevAddress QTY. MECHANICAL PERMIT FEC IV I
V 1 certify that 1 have reed this application and state that the above information is MECHANICAL.FEF.
acorrect❑grain comply with ill city cirri county oNinances sod stem laws relating to PERMIT ISSUANCE 3 7
V z building construction.and hereby aushoma represernadvesofthiscity to emerapon the CONSTRUC IONTAX
Wove-mentioned Property for inspection Purposes. ALTER OR ADDTO MECH.
(We)agree to save,indemnify and keep hornless the City of Canadine again,
liabilities,judgments.coatevtdeapenuawhich may in any way eecm men said City AIR HANDLING UNIT(TO Ig000 CFM)
in
tt afthegrantin fthts uni
AI
t.
wd R HANDLING UNIT(OVER 10.000 CFM)
-w EXHAUST HOOD(W/DUCT)
Signal..of ApplicanUCo trazto Dam PAID
HAZARDOUS MATERIALS DISCLOSURE I HEATING UNIT(TO 100,000 BTU) Date Receipt
Will the applicant or future building mcupant store or handle haz4vdous material HEATING UNIT(OVER IW.OW BTU) OAL:
ss defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Sewion 25532(x)? VENTILATION FAN(SINGLE RESID)
❑Yea ❑No Wo I
ISSUANCE MATE
Will thea licamnrfuturebulldin cu tusse tordevical whichemit BOILER-COMP OFF OR 100,000 BTU)
PP Bac Teo 9uipmen n
hezallous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100.1100 BTU) aV Ay
Dinrict?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. V l s l ,rya�'
I have read the lawasio e;materials requirements under Chapter 6.95 of the OCT
1T
12 1994
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that
if the building does not currently have a renam,that it is my responsibility to notify the
occupant of the requirements which must te met prior to issuance of a Certificate of CITY Ur wrerl I IJVU
Occupancy.
Owmeror euthmieed agcut Date TOTAL: 141 -7 ISSUED BY:
OFFIC