26782 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B H.1I G-RLECI'RI M, PERMIT NO.
APPLICATION/PERMIT PI.U.MIIIN(;-MECHANICAL, 26782[k f O f�
RUI1,131N1:DIVISION BUILDING PROJECT IDENTIFICATION Lv I oL
BUIL`NGAD`RESS: SANITARY NO. APPLICATION SUBMITTAL DATE
LrI/ 1
OWNER NAMW O PITONE: CON71t CTORS AM': LIC NO:Oil 0 N/C CONTROIA
RCH CRN I E192: LLLICNN•O: ADDRESS: I ❑
109 D '64-
M�w
r /1Tn0 C'
cOWACT: PHONE: RUIhDING PERMIT INFO
QTY. ELECTRIC ERMIT FEE
BLDG ELT;CI' PLUMB MECII
PERMIT ISSUANCE Ise
LthatIaEDCONRACIdunder OvisimixcfClATION APPLIANCES-RESIDENTIAL _Irnl ptL�;pCRIPT
n�% IberebY affirm CEN E licensedunda provisDECL DECLARATION
9(commencing with /vL`LA"^/'E�
W'00 Serum 70)m of Division 3.f me Business and Professions Code,and in,license is in PANELS
<aVF full tonsme and effb .. 7 Liebe �kQS1yD UPT0208AMPS
- W Li cee Class C! l -I
m 6 y Oua Comrncnn 201-1000 AMPS
Fy% A c111'rECTS DECLARATION SQ,FT.FLOOR AREA S/SQ.19'.
'l_Osn�
1 understand city plans shall be used as public records. OV15R IQTO AMPS
_L W SIGNS ELECTRICAL.
<ymj Licensed Professional
W wee< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
X06 V I hereby affirm that I am exempt from the Comm for's License Law for dw
W 3 a y fallowing reason.(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
f—°-0< which requires a permit to consuuct,alter,improve,demolish,or repair any stromurt
�'mY' prior totes lemance,al so requires the applicant for such pemniuo file a signed statement POWER DEVICES
bog mbar he is licensed pursuant In the prrvisioma of the Contractors License Low(Chapter
a e.0 9(crmmencing with Sada.9W0)of Division 3of the Boniness and Professions Cale) SWI MMING POOL ELECTRIC VALUATION
W= or that he is exempt therefrom and the basis for the alleged exemption.An tion of
ti p g pion. ylPen OUTLLTS-SWITCHES-FIXTURES
F.ya not rirn]than by my undredicratfofapctmit aubjukthe applicannoacivil penalty or
not mum than five hundred dollars(5500).
ESp NEW RESIDENTTAI.ELECRt _SQ f4. STORIES TYPE CONSTRUCTION
�F12 ❑ Laownavndeproractomrmyempended withwageaxameiSec.compensation.
1,3� will drthewons andtheno Contractor
intendede Law
not apply.to an Business
andof I
pro erty oh ons Calc:The Co thereo s License Lew such
ria apply lf an owner is
own coo whob,provi improves such improvements
messactrudedimselfarthmugh M1f,
I led that ins t t t deJ nndfereJ for sale.If, OCC.GROUP EA11
TScmp theespnrvi provemensarcneye enhuwcveq the buildingnr impravemem is sold witM1in one yemofcompletion,the owner- TOTAL:builderwill have the burden ofproving thin hedid not build or improve forpurposo ofsode.)' QTY. PLUMBING PERMIT FEE
❑ I,aownerofthepmpeny,amexclusivelyconuwtingwiNlicenu ...mors.. FLOOD LONE
consumer the project(Sec.7044,Business and Rofessious Cale:)The Contractor's
License Wwdoss^ot apply to an ownerofpropeny who builds almprovesthereon.and PERMIT ISSUANCE
who contracts for such projects with a coo actons)licensed puauu^uo the Contractor's
License law. ALTER-DRAIN&VENT-WATER(EA) PEE SUMMARY
❑ 1 am exempt under Sec ,B&P C for this reason BACK MOW PRO'I ECT.DEVICE OUTSIDL PEES
SANITARY YN
Owner Date DRAINS-FLOOR,ROOF.AREA,GOND. RECEIPT
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑tickers'
affirmthntl uramox nificam ofc e,lhcrcadf(insuraa Lab C.)sore Ofwhich lTXTURES-PER TRAP RECEIPI'p
mkeri Compensation lnsaance oracertified copy thertof(Ss.3RIl0.lab C.)which PARK FEE YN
covers al I employees under this permit. GAS-BA SYSTEM-I INC.4 OUTLETS RECEIPT p
Policy M BUILDING DIVISION PEES
Company GAS-EA.SYSTEM.UVER 4(EA) PLANCHECK FEB
❑ Certified copy is hereby furnished.
G_temified copy is filed with the city inspection division. GREASF/INDUSTRI,WASTE INTERCEPTOR GRADING FEE
i'.-/
CERTIFICATE OF EXENULiON FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not hecompleted ifthe Penni,is for one hundred dollars P$100) SEWER-SANITARY-STORM EA.201 ENERGY FEE
lrss)
IOcnifythm intheperfnrmanceoflAc work lbrwhich this permit is i.vsued,I shall WATER HEATER WNHNOELECTR
not engdoy any pen^^ in any manner so as to become subject to the Workers PAID
Compensation Luwsof Cnlifomia. Date WATER SYSTEM/BEATING Date Receipt#
O z Applicant
Z0 NOTICE TO APPLICANT.If.after making this CeraiGcale of Exemption.you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
become subject..the Wakoes Compensation provisions of the Labor Cale,you must BUILDING FEE
forthwith comply with ns such provisioor this perbe mit shall deemed revoked.
4 Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hby affirm ihuuhere is a construction lending agency far the performance of
U % emIE
C E
U O the work for which this psrrmit is issued(Sec.3097.Civ.C.) 'I'O'I'AL: ELECTRI
IsnJefs Name PLUMBING FEE
0 F-' Lsmder'sh.Jdress QTY. MECHANICAL PERMIT FEE
T..) I ornlfy that I have read this application and.oma that me above information is MECHANICAL FTP:
correct.Iagreemcomplywithallcitymalcourty.maimersnnd state laws relating to PERMIT ISSUANCE
F" huildin,imstruction,and hereby a^thorim mpresentativeso(this city to enter upon the CONSTRUCTIONTAX
U Z uh^vc-mentio^cd properly fm'msproam purposes. ALTERORADDTOMECII.
(We)agree to ensu,indemnify and keep limoless the City of CuKr ino against
l iabilities.judgmems,em s which may in any way accrue agairimmid City ATRUANDLINGUNI'I'(T'OIO.000CFM)
in con t renting o(Nisse il.
'' AIR HANDLING UNIT(OVER IU,000 CFM)
azure pplicunVCmnmctor Dan, EXHAUST HOOD(W/DUCp
PAID
ITALARDOUS MATERIALS DISCLOSURE, HEATING UNIT(TO 100,0110 BTU) Date Receipt
Will the upplicum or future building Occup im store or handle hmardous material HEATING UNIT(OVER 100,000 BTU) TO'T'AL
nt :
as deed by the Cupenino Municipal Code,Chapter 9.12,and the Health and Safety
Cod,Section 25532(uy! VENTILATION FAN(SINGLE RCSID)
❑Yes —❑No
BOILER-COMP LIHP OR 1(0,000 BTU) ISSUANCE DATE
AdkWill the applicmmrfmurt building^ccupmtnuequipmcmordeviceswhichemim
froc ous air communist as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100.000 BTU)
mice?
❑Yes ❑NO NEW RESIDENTIAL MECfI. SQ.tT.
I have read the hvardous materials regdremems time,Chapter 6.95 of the
California Health&Safety Code,Sectimrs 25505.25533 and 25534. 1 understand Nat
if the building dues Out curamly have a umant.that it is my responsibility mortify the
occupant of the rtquirement which must be met prior to issuance of a Cenifinenne of
Occupancy.
Owner or vuthorieed agent Date TOTAL: ISSUED BY:
OFFICE