26169 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUIr.DIIO-ni.. PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 26169
BUILDING DIVISION BUILDING PROJECT IDEN'J'IFICAI'ION
BUILIDIIING/ADDDRFSS. /\� SANITARY NO. APPUCsXlOOaN SUBMUMAL DATE
f�V L v w • ' ' '� —+ Us LOT# Z /k�
OW ' S NAME _�s , PHONE: CO O CfOR'5 NA ' LIC NO: J C`!I
{F• !W'�J` N/C CONTR01.p
• ARCHI IhUl t G CCH: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECII
PERMIT ISSUANCE El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Qwz I maphy aflimnhat Ino ticcneedinderproomminsof0apler 9(commenting with
�U00 Seutiu.7000)ol'Divlsion3oflhc Business and Prohssions Code,and my license is in PANELS
full more and It
FluVi fiance Clea Lic.# UP T0200 AMPS `mow
rn,6y Date Contractor 201-I"AMPS
'
ZOHz ARCHITECPS DECLARATION OVER IUW AMPS SQ.IT.FLOOR AREA S/SQ.IT.
O Z_❑ 1 understand my plans shall be used as public records.
PL SIGNS ELECTRICAL
6.1 -4 ELicensed Professional r II J V
= M< OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC. N�
xC.0 I hereby affirm that I am exemq from the Conunctors Licence Law for the _
uJ3t+.r~i+ following Jason.(Section]031.5,Business and Professions Code:Any city mcoumy TEMP.METER OR POLE INST. Il
F which requires o Permit to construct,alter,improve,demolish,in repair any smamre — 1 )
of prior to its issuance,also requires the applicant for such Permit file a signet stmemem POWER DEVICES LJ
that he is licensed parman to the provisions of the Cmtrntrs License Law(Chapter
u. M SWIMMING POOL ELECTRIC
pp,, 9(commencing with Section 7")of Division 3 of the Business and Professions Code) RATIO
W.rn nrthm he i.v exenhpt thcreftom and the basis for the alleged exemption.Anyvidittion of OUTLETS-SWITCHES-FlXTURES
FZ_a Seclion 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of
sF-G t rc Than Ove hundred Jollnn'($SW). NEW RESIDENTIAL ELECfR SQ.FT.
m Less mwncr lathePmpeny,ormy employees with wages as theirsole compensation, Q STORIES TYPE CONS'THUC'1'ION
a3— ill the work,rend lhaauucturc isnm imm�dedoroftrcd for sele(Scc.]fH4,Business
and Professions Code:The Commcwrs License Law does not apply to an owner of
property whobuildsor improves Emmon.and whodma such work himselforthrough his
OCC.GROUP HES.UNITS
maniamployers,building or ithatsuchimprovementsarcnot intendedmoffered forsale. r-
however,the building or improvement is sold within one yearofcompletion,theowncr- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale')' QTY. PLUMBING PERMIT FEE APN
❑ I,asownerofthepropeny.amexdusivelycons tingwiNlicensedconwionto I1.00D ZONE
nswa the project(Sec.7044,Business and Professions Cove:)The Contractor s
License Lawdoes not applym an ownerofpropeny whobuildsm improvesthemmn,and PERMIT ISSUANCE
who contracts for such projects wit acomparto(s)licensed purswmto the
Comment,'a
ALTER-DRAIN&VPNT-WATER(FA7 FEE SUMMARY
License Lew.
El1 am exempt under Sec. ,B&P C for this reason UTSIDE FEES
BACK FLOW PROTCCT.DEVICE SANITARY Y N
Owner —Dan— DRAINS-FLOOR.HOOF,AREA.COND. RECEIPpp
• t v WORKMANCOMinear mIONDECLAHATION SCH(lOL'1'A% Y N
❑ Irshereby Coraflimnhatlhavc acenificate ofconunuo sdf-inmre,nrucmificate of FlXTURES-PER TRAP RECEIPI'p
Workehv Compensation lnsumnce nr certified copy thereof($a.3gW,Lnb C.)whicb PARK PIiIi V N
acv all rm,loyec's order this permit. GAS-GA.SYSTIiM-I INC.0 OUTLETS RECEIIT#
Policy p BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASMNDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE MAP SOILS PEE
COMPENSATION INSURANCE
'Dissection lad loth aompletW lithe perm,is forms hundred dollav(5100) SEWER-SANITARY-STORM EA,200FT. ENERGY ME
orless.)
I anify thin in the,performance ofthe work fm which this permit is issued,l shall WATER HMTER W/VENT/ELECTR
no employ any person in any mourner to as to become subject to the Workers' PAID
Compemouion laws of California. Dam WATER SYSTEMIMEATING Dote Receipt#
O Z Applicant
Z C) NOTICE TO APPLICANT:if.afe,making this Cenifcam of Eacmption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
rn hcome subject o the Workers Compensation Provisions of the labor Code.you must
� ; forthwith comply with such provisions or this permit shall be domed revoked. BUILDING Iq!E
(� CONSTRUCTION LENDING AGENCY SEISMIC TTI?
CW
= Z I hmhyuBirm thut the.is a commit lending agency for the pedormunce of TOTAL: ELECT IC ITHE
U 0 the work far which this permit is issued(Sec.3097,Civ.C.)
(1ti (r Lcoba's Name PLUMBING PEE
!-� Leaders Address QTY. MECHANICAL PERMIT' FEE
Q (, 1 cent,Ila,1 have read this application and slate that this above information is MECHANICAL PEE
r LU correct. I agree m comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
building construction,and hereby authorize reposenativesefthiscity to enter upon the CONSTRUCTION TAX
U Z abovcmmnumad pmpar y for inspection puryous. ALTER OR ADD TO MECIL
(We)agree to save,indemnify and kap harmless the City of Cupertino against
Iiabilities,judgments,emu wdexpenuswhich meyin any way accmeagainst said City AIR HANDLING UNIT(TO 10.00D CFM)
in consequence of the greening of this permit.
3N AIR HANDLING UNIT(OVER 10,000 CFM)
j_
EXHAUST HOOD(WIDUCD
Sign arc of ApplicunVCommcmr Drs¢ PAID
I IAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,00)BTU) Data Receipt#
Will the applicant or future huilding occupant store or handle hamrdous materialTOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 1 W,(IOU B'IV)
Colo,Satin 125532(.)'t VENTILATION FAN(SINGLE RMID)
❑Ye.. ❑No
ISSUANCE DATE
BOILER-COMP(311P OR 100,M)BTU)
Will theuppliwm nr fmurcbuildingoccupanmseeyuipmem ordwices whleh emit q pp
hazmd .0110 A
ouv air contaminants M defined by the Bay Area Air Quality Management BOILER 100BTU) • B
.. DixvicR
❑Yes ❑No NEW RESIDENTIAL MliCll. SQ.FT.
I have rend the hazardous materials"mmo+ents under Chapter 6.95 of the MAR 21 1994
Culifomia Health&Safety Code.Sections 25505,25533 and 25534. 1 undemanJ that
if the building clues not currently have a anion.that it is my msponsibility to notify
occupant of the requirements which must be met Prior to issuance of o Certifieam of Vl- V yr'
Occupancy. yI�,CFII/f(f�xyl,�f�J!/
Owncroramhnrired agcnl Do¢ T ISSUE[)BY:
OFFICE