26168 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO tl Lk-(TIILDI\.-E 'RI A PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.-MECHANICAL f�� 'I [kO
BUILDING PROJECT IDENTIFICATION L 1OQ
BUILDING ADDRESS: SANITARY NO. APPLICA'HON SUBMITTAL DATE:
QRem UNITp LOT. � ^`
OWN12RS NAME: PHONE: CONTRA OR'SN ME: LIC NO: NIC CONTROL#
21 923-3i8 /
WRCHI'MCT/ENGINHER: LIC NO: ADDRESS: ❑ -
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
�l
4BLI)0 E�ECI'_ PLUMB ITCH
�fi{�I f15V�izi �23- �Iop?2 PERMII'ISSUANCE � a•IT�X �L��/,
LICENSEDCONTRACTOR'SDECLARATION APPLIANCP_S-RESIDENTIAL JOB DESCRIPTION
CCz I hercbyaffirn that l am livered under provisionsofCTapter9fwmmencing with
4100 Scnion7g01 of Divisinnlof the Business nnJ Psofessions Code,and my l'mcnse is in PANELS
IL❑ full force and effect.
TUUUP TO 210 AMPS
Fzm License Class Liaa
m<c Dam Contractor 201-1000 AMPS
b- so ARCHITECTS DECLARATION SQ.FT.FLOOR AREA g/SQ.FI'.
70trs— I undersnd my plans shall be used ub .,lic recndOVER IOW AMPS
oz—o masp
y ; SIGNS ELECTRICAL
Q �
Licensed Ihnfecsional
ayceQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. LL
.°KOyF I hereby affirmsat exempt that I sexempt from the Common's License Law for the 4I L 'Ittog
Wy :t4' following reason.(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR TOLE.INST. T
"5 which requires a Permit m contact,alter,improve,demolish,or repair my swetu,
"t POWER m its issuance.nlsore oirestheu applicant forsuch count file a signedstatement PoWER DEVICES
prior 4 PP Pcrmi
WK<O that he is licensed pursuantto the provisions of the Contractor's License Law(Chapter
�Kc 9(commencing with Section 7000)of Division 3ofthe Business and Professions Code) SWIMMING POOL ELECTRIC �k VALUATION V/a
=Qy n in or that he is exempt therefrom and the basis for the alleged exemption.Any violation of 2NS��� I �'
T Sermon 713 L5 by any applicant for a Permit subjects the applicator Ofll'LFTS-SWITCHES-FlXTURES /no a civil penalty of _VVV�k
re thfive hundred dollars($5W),
C�00 ❑ml,mownerof Neprol<nY.nrmyemPlnyeeswith wages us theirsolc<nmPcnsation, NEW RESIDFNTIALELECflt SQ.IT STORIES TYPECONSTRUCION
,3a2 will do the work,and thestrucam,i,a not imemdermidfered for cal(Sec.7844,Business I 1)
and Prafesdom Code:The Contmaors License law does not apply m an owner of {. V
property who builds m improves thereon,and who docs such work himaelf-through his
employees.provided that suchimprovements are notimendedoroffertJ forsale.IL OCC.GROUP RIS.UNITS
builder
the burdenofpmem that
of build or improetinn,Nrpose of �A 0
huilJcr will have the harden of proving that be did not build or improve for purpose of
mownerofthe properly,am exclusivelyconanOt.,with liceru4 commours 1. QTY. PLUMBING PERMIT FEE FLOOD ZONE AVN
wnuu. he pmjeet(Sec.70,P1.Business end Professions Code:)The Contractor's
License law doesnot apply to an ownero(property who builds mimprrvesthcrmn,and T PERMIT ISSUANCE
who connects for such PmJects with o contractors)licensed promicauo the Connector's
License L.W. ALI HR-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 ten exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE ILFS
SANITARY YN
Owner Dam DRAINS-FLOORROOF.AREA,GOND. RECEIPTp
WORKMAN COMPEN ,SATION DECLARATION SCHOOLTAX Y N
F9 Ihcrchy nfOrm NmlM1avcacerificmc ofconsemmsclf-insure,oraccnificam of FIXTURES-PER TRAP RECEIPT#
I Norkeri Compensation Insurance or a certified copy Nercof(See.3800.Lob C.)which PARK FEE YN
camous all employee's under this permit. GAS-FA.SYSTEM-1 INC.4 OUTLETS RECHIPT p
Policy a BUILDING DIVISION FEES
Company— GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEF,
❑ Cenitied copy is hereby famished.
❑ Certified copy is filed with he city inspection thstoor. v OREASEWINDUSTRL WASTE INTERCEPTOR GRADING FEE a"
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE hh
I'M%section need not be completed ifthe permit is far one bondqupul ars(Ss100) SEWER-SANITARY-STORM EA.20BT. ENERGY FEE
or less.) ��//
Pcenifythat in the Parformear,afthe work for wh 'h i iasis hall WATER HEATER W/VFBU/ELECTR
not employ any Mourn in any manner so as m base jeer to the minces PAID
Compcnamionlawsof Coliform.. Date WATER SYSTEM/TREATING D e Rc P
r Q z Applicant
zO NOTICHIOAPPLICANT:ILaRer ranking this Ccnifcum of option you should NEW RESIDENTIAL PLYUL SQ.FT. TOTAL:
F' Tn become subject to the Worker's Compensation provisions of the L bor Code,you must
li � ? forthwith comply with such Provisions or this permit shall be decmW revoked. RUILDI ,F '
Q CONSTRUCTION LENDING AGENCY SEISM( : O Wit, 60
z I hereby affinm that them is a construction lending agency for the performance of A
U O the wok for which this pcmtit is issued(Set.3097,Civ.C.) P.1, -ILC O
Lender's Name MBING Il':
Lenders Address QTY. MECHANICAL PERMIT FEE
U I certify that 1 have mad this application and sum that Ne above information is MF.CHANICA.FEE i
correct. I agree to comply with all ciryand countyoNinenc datatelawsmlatingto PERMIT ISSUANCE I^
1,01hngnmuruction,and hereby amhnrim represcmatives f hlscitym enter upon the C(INSTRUCI ON TAX
U Z above-mnnlened property for inspecdun purposes. ALIRR OR ADD TO MSCI I.
(We)agree to save,indemnify and keep harmless Or City of Cupcnino against
liubilities,judgmcnu,costs and ex r swhichmrytroy yaccmeageinstsaid City AIR HANDLING UNI'r(TO 10,000 CFM)
he grantin to i permir.
'2 AIR HANDLING UNIT(OVER 1010X1 CFM)
SiBnelurc nt ApplicanUGnnrr t X a EXHAUS HOOD(W/DUC9) PAID
RDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.IXI11 BTU) Date Receipt#
Will the applicant or future building occupant store or handle havrdous material HEATING UNIT(OVER 100,000 BTU) I
as defined by the Caperfirm Municipal Code,Chapter 9.12,and the Health and Safety
Code Secfu n 2 532 u)7 VFNNTILATION FAN(SINOLC RESIUI
47-
❑Yes ❑No
BOILER-COMP 3HP OR 100.000 BTU) ISSUANCE DATE;
Will air contaminants
marts as building by the
nBay equipmentQualit Management P p
nct? air<omaminants n defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) I— #'i ' Q
tl {ny./.(j�/
`c ❑Ycs ❑No NEW RESIDENTIAL MFCH. SQ.FT. #tlltl/
Z
1 have read NN
e haruous materials requimmcros under Chapter 6.95 of the p9��
California Health&Safe,,Code.Sectio25505,25533 and 25534. 1 understand that CI
if the building does not currently have a tenant,that it is my responsibility m notify the l
occupant of the requirements which must he met prior In issuance of u Cemlficote of �I LUf't Lr
/I
Occupancy.
Owner or audsoriud agent Dae L: % ISSUED BY:
OFFICE