26581 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
IMUDING—RUTICTRICAL PERMITNO.
CITY OF CUPERTINO PLUMBING-MECHANICAL
BUILDING DIVISION APPLICATION/PERMIT BUILDING PROJECT IDENI'IF'ICA-1'[ON 26491
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITI'ALDATE
P # . L�JI. ^• -�
2l • � UNITS LOTH
OWNERS NAME: PHONE: CpNTRAUPORX NAME: LICNO:
Cu�� `LL •7� NIC CONTROLS
0 ARCH]FECOENGINEER: LIC NO: ADDRESS: L• ❑
t
CONTACT: P ONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT ;ITEE
y�S SIS'I-ol L4-
is
ELECT PLUMB MI CH
PERMIT ISSUANCE CCyJJr 0_ 1E�, t!W
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
CmZ Hamebyaffirmthat l am9
licemad umbaprovisiona irchopaer (commencing with JOB DESCRIPTION
a00 Seclina 7")of Divis Sof the Business anO Promssiom Code,and my license is in PANELS
V u full force and effaL n
vFj<y D'atenaeC�Conlracpar Zk IJPTD 2t%IAMPS s .✓ver+\,�
201-1000 AMPS
RCHITECTS UECIARATION SQ.IT.FLOOR AREA S/SQ.FT.
Z�N 7�. OVNR 1000 AMPS
1 understand my plans shall be used m public records.
SIGNS ELECTRICAL I4, g 7 .
to Z 7 l0
4—YE Licensed Professional
ECW OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
�44�dd OWL) I battery affirm out I mor exempt from the Contractors License Law for the p) ff11
W 3 a y following reform.(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST. M rf I •v9
(:4.1 ON 5 which require,a permit to construct,.1m,improve,demolish,or.,is any aweturs
poor o its issuance,also roporesthe applicant forsuch Permit o rile a signed statement POWER DEVICES
C a a O
for he is licensed pursuont to rhe provisions of the Contractor's License Law(Chapter
4pxp�' 9(mmmencing with Section]000)of Division 3oflhe Business and Professor.Cade) SWIMMING POOL ELECTRIC VALUATION
W nto or that he is exempt thertfrom and the basis for thealleged exemption.Any viohtiono( +
ljI_b '/1--�
,Z< Section 7031.5 by any applicant for a permit subjects the applicant a OUTLETS-SWITCFLPS-Fll(TURES e civil Penalty of RES
�TD not marc than fve hundred dollars($50B. NEW RESIDENTIAL ELECfIt �.eSQ.FT,❑ I,asownmrafthepropcoy,moryemployeervith u
wagaallboarlecompentadon, STORIES TYPLCONSTRUCDON
y will dothe work,and thesuvchamisnotimended oroffercA forsale(Sec.]044.Business
and Professions Cede:The Contmctar s License Law does not apply to an owner of
pmperry whobuildsorimproves thereon,andwhodoessuchwork himselforthmugh his
OCC. RES.UNITS
n employms.providedthat such improvements areamintendedoroffered formic.If,
however.the building or improvement is sold within oneyear ofcompletion,the owner. TOTAL:is 11 '7
builder will have the burden of proving bad he did not build or improve for purpose of '
sane.). Q'fY, PLUMBING PERMIT FEE FLOOD ZONE APN
❑ I,sea rof the prvpedy.emexduaivelywnunnmg wird licensed contracronto
answer menpmject(Sec.7014.Business and Professions Code:)The Contractor's
License Luwdocs noaupplY to anownerofampary who buildsmimprovee therton,end PERMIT ISSUANCE
whocontracu for such projects with aresom tors)licensed punuamttumc Canaan, ALTER-DRAIN&VENT-WATERI
License Law. l > PEC SUMMARY
❑ I am exempt under Sec. B&P C for this rearm BACK FLOW PROTECT.DEVICE SAT' LLS
NITARY YN_
Owner D.
DRAINS-FLOOR,ROOF,AREA,GOND.
' RFCEP
WORKPENN DECLARATION SC300LA% Y
N
❑ IhmbyammthetihneacmifateofcounitoselGinsurt,oracr6fceteof
FIXTURES-PER TRAP R IPI'p
' Wmkm'Compcnseaion Insurance orecmilied copy thercoF(Sec.J800.Leb C.)which PARK FEE Y N
covers all employea s under this permit GAS-EA.SYSTEM-I INC.4 OUTLETS RB
Policy# BUILD[ S
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FELE
❑ Certified copy is hmby famished. j` W-00
❑ Cmifid copy is filed wird Ne city inspection division. GREASHINDUSTRI,WASTE INTERCEPTOR GRADING FEF.
1•W
CERTIFICATE OF EXEMP'TON FROM WORKLRS' GRPASETRAP SOILS IEE
COMPENSATION INSURANCE
(Thissection aced not b<complemdifthe pcnnit is foronehundreddollas(SIM) SEWER-SANITARY-STORM EA.2WFT. ENERGY FEE
or less.)
I modify that in the prommuncc of Ne work foe which this permit is issued,Imall WATER HEATER W/VENT/ELECIR
not employ any person in any manner so m to become subject to the Workers' PAID
Compensarionlswsof Califomia. Data WATER SYSTBM/fRRA'ONG Dam Receipt#
Z Applicant
Z NOTICE TO APPLICANT:If after making this Certificate of Exemption,you should NEW RESIDENTIAL PUSH. SQ.ET. T'O'TAL:
f-� becmne subject o the Wmkeh Compulse4an pmvisiom of the labor Code,you must BUILDING FEB
la^ ' foodwith comply with such provisions or Permit shall be deemed revoked. 6 C.• I{D
LS1A CONSTRUCTION LENDING AGENCY SEISMIC FEE t •Ol
Z hereby affirm Nat there is a construction lending agency for the performance of TOTAL: ELBCIRIC FTiE 1
U O the work for which Nis permec
it is issued(S .3097,Civ.C) •7 r 1�
Lender's Nome
0 F Lender's Address QTY, MEC14ANICAL PERMIT FEE PLUMBING FEE: 1%41 .I
U I ramify that I have mad his application and sane Net the above information is MECHANICAL PEE
>1 a correct.I agree to comply it all city and county ordinencea and sum laws re luting a PERMIT ISSUANCE 2
�•' 0 building construction,and hereby authodse representatives ofthis cityaenter upon the CONSTRUCTION TAX
U z above-mentioned property for impassion purposes. ALTER OR ADD TO MITCH.
(WC)agree to save,indemnify and keep hampers the Ciry of Cupertino against
Fusiones,judgmenu,casts and expenses which may in any way accrue against said City AIR HANDLING UN IT(TO 10.00)CFM)
�enceco���er ftheglvntingof permit.
o ^-[ tlJf+ / �� I � AIR HANDLING UNIT(OVER IO,OW CPM)
Signature of Applciamu Contm �Y(�' 10 ,/pL,Dam EXHAUST HOOD(W/DUCT) PAID
EIAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 1011,000 BTU) Date Rec<iptp
Will the applicant Or futum building cmupantaam,or handle barardous material HEATING UNIT(OVER 100.00s)BTU) TOTAL:
as defined by the Cmerino Municipal Cede,Chapter 9.12,and the Ilealth and Safety
Cade.Section 25532(a)] VENTILATION FAN(SINGLE RESID) re n f^
❑Yes El No
ti- #•• ISSUANCE DATE
Will thea licanmrfutum building mcu Luse cordeviceswhemanuit BOILER-COMP(3HP OR IOQ000 BTU)
PP 8 pan Area Ain 1 Hy�//aa���d/µ�
berardays air contaminants us JeflnrA by the Boy Area Air Quality Management BOILER-DDMP(GYER 10(1,000 BTU) OCT '" � 19"
i Dioncl
❑Yes ❑No NEW RESIDENTIAL MECII SQ.R.
1 have mad the hazardous materials requirements under Chapter 6.95 of the CITY U' wrrhI11W
California Heath&Safety Code,Senteas 25505,25533 and 25534. 1 understand that
if the building docs not currently have a tenant,that it is my responsibility to notify the !f/
Occupant of the requirements which must be,met prior to issuance of a Cenificam of
Owner or emhorimd e8em Data TOTAL:FN' ISSUED BY:
OFFICE