26600 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOB011u .-6 h N[CAL PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. f�[vv� O
BUILDING DIVISION BUILDING PROJECT IDEN'TIF'ICATION G
BUILD�ING1 ADDRESS: 11J/3 {��� SANITARY NO. APPI.IGTON SUIPATPAL DATE
L..{yfAyi4l FLI UNIT# O`' I LOTN G
112)
OWNERS NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
,^, NIC CONTROL
VI
RCHI'IECf/FNGINEHI: LIC NO: ADDRESS:/�
CONTACT: PH P.: BUILDING PERMIT INFO
6'5. QTY. ELECTRIC PERMIT FEE E PLUME
fl):Gy
,Jw ZZ / PERMIT ISSUANCE a7Cr
LICENSED CONTRACfOR:S DECLARATION APPLIANCES-RESIDENTIAL
I hereby affirm that l am licensed under (Chas 9(commencing with LOB DESCRIPTION
J40Z prdviaifeso pm
F^100❑ Section]IXIO)of Divisio of the Business and Professions Cook.and my license is in PANELS
�uU full force end ellen. 67-167-119
(QWE Licenu Clad LiaNUP TO 200 AMPS
yQd Date Cromwell, TI III-IOW AMPS
FyZ RCHITECI"S DECLARATION SQ.PT.FLOOR AREA $/SQ.FT.
Z O,ZOVER IBEB AMPS �ym•� -��
OZ-0
1 undcrswnd my plana ahnll be used ee public recoNs. ga$af!$tiS�l I UO�
py SIGNS ELECTRICAL K�Y/YL`J� Q
LQ' � Licensed Professional
�� OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. l' / n 1 0O
�Oa. 1 hereby affirm thin 1 am exempt from the Cmianconx License Law for she 41 QT �••L I
W 3 LL following mssan.(Section 7031.5,Business surd)Professions Code:Any city or county TEMP.METER OR POLE INST.
F(:O a which requires a permit to construct,a ter.improve,demolish,or repair any structure
prior to h%issuance,also requires the applicant for such Permit u rile a signed summer POWER DEVICES
Q p that he is licensed puma. tto the provisions of the Common's License Law(Chapter
Ozaddons SWIMMING POOL ELECTRIC VALUATION
ddoLL 9(ronweisexemlt therefrom
F100)oe Division Softheed exemption.
viola Code)
�aN
or heir IS
y.,Iimand the basisforlsym.the thedexempti to civil
of � 9
4 Section 703 LS by any applicant forapermit subjecuthe epplicannoacivil penalty of OUTLETS-SWITCHES-FIXTURES 1S
t ram than five hundred dollars($510d) S'T'ORIES TYPE.CONSTRUCTION
SdORESIDENTIAL.ELF.CTRSQ.ET. �L
W es n❑ Luvnwnerofshelceperty,ormyempiny«a withwageasstheirsolecompenmtion, NEW
L will dothe work,and theaoucture is not intendedoroffemd(orcale(Sce.]044,Busimmss
and I'rofessionx Cade:The Commerce.Li«u nLaw does me apply to an owner of
property wholson sor improves thereorand whodoes such work ldmselfonhomgh his OCC,GROUP RFS.UNITS
awn emp loyees,Provided that such improvements sure nos i coded or offered for sale.If, 2
however,the building or improvement is sold within one year ofcompletion,the owner- TOTAL: Tj •3J
builder will have the burden of proving that he did not build or improve for purpose of
sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
Ell,os rofthepmpmy,amexclusivelyconr tingwimhlicenaedconwctorsm
construct the project(Sec.7844,Business and Professions Code:)The Comracsor's
License Law deennmt apply manawnerofprrecrsy whobuildsor improves thereon,and PERMLTISSUANCI3 31..-
who contracts forsuchpmjeaswithawnwesor(s)licensed purmant tmhe Conwgors ALM FEE SUMMARY
License Law.
❑ 1 am exempt under Sec. ,B&PC for this memo BACK FLOW PROTECT.DEVICE
SANITARY Y N
Owner Dale DRAWS-FLOOR.ROOF,AREA,COND. RECEIPTIt
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ihembyaffirmthutlhaveacenificateofmnunuoulf-i.,..,«.. rteateef FlXTURFS-PER TRAP RECEIPTN
Workeri Compensation Insurance ore ceniried copy themof(Sce.3000,Lob C.)which PARK FEE Y N
covers all employee's under this pemmis, GAS-G.SYSTEM-1 INC.4 OUTLETS RECEIPT N
Policy N BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OYER 4(EA) PLANCHECK FEEIN.,s
❑ Candied copy is hereby furnished. ZO V V
❑ Cenifiedcopy isfiled with the city inspection division. GREASEnNDUSTRL WASTE INTERCEPTOR GRADING FEE Iqt-op
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section nccd not h completed ifthe permit is forone hundred dollars($IW) SEWER-SANITARY-STORM EA.20JJPT. ENERGY FEE
or less.)
I comfy that in she performance of the work for which this permit is issued,l shall WATER HEATER W/VFNTJELECIR
net employ any person in any manner so a to become subject to the Workers" PAID
Compensationlnwsof California. Date WATER SYSTEM/DtfiATING 'Dam tt ptN
O z. Applicant ,Q.r
0 NOTICE TO APPLICANT.If.after making this Cenificare of Exemption,you should NEW RESIDENTIAL PLACE.l jS___SQ.FT. 05 '!, TOT L:
p] become subject 1.he Workers Compensation provisions ofdre Labor Code,you mum
a ; forthwith comply with such provisions aphis isminshall he deemed revoked. BUILDING FEE
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE O
a z I hembyuffirm dmanhem isrimalmcsion lendingagency far she performance of 4 ELfiCIRI
L) 9],O the work for which this permit is issued(Sec.30Co.C.) TOTAL: 3 y
Lander's Nome PLUMBI M
Q
0 (~ Lender's Address QTY. MECHANICAL PERMIT FEE
V 1 certify that 1 have read this application and state that she above infmration is Mr:CHANICAL iE n
correct.l agreeto comply with all city and county ordinances andsum laws mla0ng to PERMIT ISSUANCE 7s ->
�m buildingconsteuclon,and herebyacthan.repcaeandiesofthia city the CONSTRUCTION T K
V '� tab Ire-mentioned Prpety for inspection purposes, ALTER OR ADD TO MECH.
(We)agree to save,indemnify end keep homeless the City of Cupertino agaimt
Iiabilitia,judgments.costa and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
in copse�ulp (the granting of h ppFlFFFn�i�.
/Q`=_ / 6/ 6I AIR HANDLING UNIT(OVER I(I,gl(I CFM)
Sigellom of Appliean/ ooees `/9jLM/ a F.XHAUSTHOOD(W/DUCU PAID
HAZARDOUS MATERIALS DISCLOSURE HEA9'ING UNIT(TO I0kL0kd BTI3) Uem Rtt<iN
Will the applicant or future building occupant start or handle hamrdom material HEATING UNIT(OVER 100,M10 BTU) TOTAL:
as defined by the Cupertino Municipal Cede,Chapter 9.12,and the Health and Safety
Code,Section 25532(q? VENTILATION FAN(SINGLE RESID)
❑Yes 11 No
ISSUANCE DATE
Will the applicanmrfuturebuildingacerasnt uuequipmenlnrdeviceswhichemit BOILER-COMP IMP OR U0,0NI(ft BTU)
harerdous air ran aturn memo as defined by she Bay Are.Air Quality Management BOILER-COMP(OVER 100,000 BTU) r
• District? Cl N®
Yes ❑Nn NEW RrSIDFNTIAI. SQ.FI'.MECH. '�-,� ft,
jD
1 have mad the huvudnus materials reuire0�8�
qmems under Ch iall 6.95 of she 'IV/
California Heahh&Safety Cade,Sections 25505,25533 and 25534. 1 understand that /s n
if she building does not currently have.tenant,that it is my responsibility to notify Ne y��Y''1 9g
occupant of she requirements which must be met prior to issuance of a Certificate of Uh/
Occupancy.
Owner m malamisd agenl Date TOTAL: 13 ISSUED BY:
OFFICE