26309 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - "'" PERMIT NO.
APPLICATION/PERMIT PLUMBING-MKCHANICAI. /� O
BUILDING DIVISION BUILDING PRIMECI'IDENTIFICA'1']ON L
BUILDING ADU Y_ LOTH SANITARY NO. APPLICATION
GSUBMITTAL
UDATE
O37- ✓-ejnv/ C7 ,f1
O iRS NJ_y.�/ Huang PHONE: D CONTRACI'OR:S NAME: LIC NO:
IY�>/ N/C CONTROL#
ARCHITECDENGINEER: LICNO: ADDRESS: fg-�
CONTACT: PHONE: �Y
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
Matz I hereby affirm that l am licensed underpruvisions of Chapmr9(commencingwith
laJ00 Section 7")of Division 3 ofthe Business and Professions Cade.and my license is in PANE" f
yUF full force and effect. //
FZu! License Class Lic.a UP TO 200 AMPS
ce201
(✓ l
Gy Dam Conoacmr 201-1000AMPS
Z FONZ ARCHITECTS DECLARATION OVER IOWAMPS SQ.FT. OOR AREA $/SQ.FT.
0 z_O 1 understand my plans shall be used as public records. � p (�a
FyFto SIGNS ELECTRICAL I!�'I / eV
Z �,a Licensed Professional _
artE: < OWNER.BUILDER DECLARATION SPECIAL CHICUIT/MISC.
XOaF I hereby affirm that I am exempt from the Conuacmrs License Law for the �, �� / u
m 3 a w following reason.(Section 2031.5,Business and Professions Code:Any city m county TEMP.METER OR POLE INST. —� b V / �f
F'aOoe_1 which requims a permit ro sent abed,improve.demolish,or repair any souncom
Q: pnonn its issuance.also realm.,theapplicamfar such pe.it 1.file.signed statement POWER DEVICES
w g G O that he is licensed pm,min to the provisions of the Conaantnrs License Law(Chapter
kTE �v
as9(cnmmcerin th Section Division 3 of the Business and Professions Code C
k Op, ewe ) SWIMMING POOL ELECTRIC
- VALUATION
odnA in that he is exempt herefrom and the basis for she alleged exemption.Any violation of
I-Z� Section 703 1 5 by any applicant for a permit sxibjectsdae.poicanno is civil penaly of OUTLETS-SWITCHES-FIXTURES
S=� a more than five hundred dollars($500). NEW RESIDENTIAL ELECTR S FT.
W, m n❑ I,asow.croftheproperty,ormyeroployees with wageaastheirsol¢compensation, Q' S'I DRIES TYPECONSTRUCI'ION
ywill do the work,and she structure is not intended oroffered for ane(Sec.21)44.Business
and Prontr
fessions Code:The Coacmr s License Law does not apply m an owner of
property w ho bu it ds or improthre
ves eon,and who does such work hi mseif or duou gh hi s
oemployees,providedthat such improm
veenlsomom immndedo,offered fo..am.If, OCC.GROUP RES.UNIT'S
however,the building or improvement is sold within one year ofcomple0on,the owner- TOTAL:
builder will have the burden t f proving that he did not build ar improve for purpose of
sale.).
❑ 1,asowner ofthe property,am exclusively contracting with licensed coauactersto QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
instruct the project(Sec.2044,Business and Professions Code:)The Cam racmr'e ' PERMIT ISSUANCE
Licen su Law docs oat uppl y to an o caner of propen y w ho bui ds or improves thcrean,and
who contracts forwch pmjecs with a conuaclnKa)licensed pusuaattothe Contractor's ALTER EA FEE SUMMARY
License Taw. ( )
❑ 1 am exempt under Sec. B&P C for this mason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN
Owner Date•
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOL TAX YN
RECEIPTp
❑ Thereby affirm thnllhaveacertifcam of consenuo self-insure,macenifcam of FIXTURES-PER TRAP pp ��(( RECEIPTp
Workers'Compen.aalion Insurance ora cmified copy thereof(Ses.3800,Lab CJ which 4O�IS(/ PARK FEE 1' N
covers all amploycu'.a under ibis perms' GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT W
Company
k BUILDING DIVISION FEES
0 Crimper!
GAS-FIA.SYSTEM-OVER 4(EA) PLANCHECK FEE
mified copy is hereby famished.
❑ Certified ropy is filed with the city hopeclion division. GREASFANDUSTRI,WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need nmbe completed ifthe permit is Toros hundred dollas($IN) SEWER-SANITARY-STORM EA,200FT. ENERGY FET;
n les.]
I certify that in the peemanmce of the work for which this permit is issued,Ishall WATER I RATER W/VENT/ELECTR
not employ any person in any rammer so as to become subject to the Workers'
Compntsetion Lawaof California. Date WA'ITiR SVSTEM(IREATING PAID
z Dale Receipt Ji
O O ApPlicam
NO'T'ICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL FUME. SQ,PT' TOTAL:
F y become subject to she Worker's Compensation provisions of the labor Cede,you must
> forthwith comply with such prnvisiros or his permit shall at deemed revoked. BUILDING PEE
yQ CONSTRUCTION LENDING AGENCY SEISMIC FEF.
.D z 1 hereby affirm that them is a comtruction lending agency for the per4mmance of
L) O the work for which this permit is issued(Sec.3092,Civ.C.) TOTAL: r, ELECTRIC FEE
F lender's Name
lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
LV I certify that 1 have mad this city
an county
and nam that the above ws relation is MECHANICAL FEE
correct,lagree mcomply with
youtymdcoumyoNtives osund stns lnwtr upon the PERMIT ISSUANCE
U Z huily i-mennswniroJen herebyamhonp purposes.
ivea of Nis city menmr upon the
V z above-mentioned propenyformnify siait purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(we)agree m save,indemnify and keep harmless the City of Cupertino against
Iiabiliucs. it enaamdeapenxswhiy -yinanyway accrue #said City AIR HANDLING UNIT CFO I0.000CFM)
m ' ✓� Iiagaflhia rem[ a `////7J
/'vAr AIR HANDLING UNIT(OVER IO,IXq CPM)
I
amreo Applican ammo Dam EXHAUST HOOD(W/DUCT) _l L
PAID <[
HAZARDOUS MATERIALS occupant store
HEATING UNIT(TO IW,IXNIBTU) Date ReceiplN
We the applicant oofuture buildingrncupam Brom or andhandle hazardousd Safety
as define]io the Cupcnino Municipal Code,Chapter 9.12,and the Health send Safety HEATING UNIT(OVER 100.000 BTU) TOTAL: 114
,
Cada Section 25532(¢)?
❑Yes ❑No VENTILATION FAN(SINGLE RISID)
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
Will the acontainantsre building by the Bay equipmentQualit Management
anes igemeit PAID
��] p fT�
hazardous air contaminants as defined by the Bay Area Air Quality Mwugemcm BOILER-COMP(OVER IO,"BTU) V A 0 v
DisW<I'!
❑Yes ❑No NEW RESIDENTIAL MECI I. SQ.FT.
I have read the hazardous materials requirements under Chapter 6.95 of the APR 2 6 1994
California Health&Safety Cade,Sections 25505,25533 and 255]4.1 understand than
if the building does not currently have a tenant,that it is my responsibility to notify the
occupant of the regoircmem,which most v mm prior to i..soanro of a Cenifrcate of CI I Y Ur NUr Cr1 I IIgV
Occupancy,
Owner oT amhodmd agant Dam TOTAL: ISSUED BY: I
OFFICE