26173 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO loUL imR,-FIX,•TRTCA. PERMIT NO.
APPLICATION/PERMIT 1'LUMBIN G-MECIIANICAL C eI
BUILDING DIVISION BUILDING PROJECT IDBNI'IFICA'I']ON v 1
73
BUILDING ADDRESS /C /l /'Y UNITM LOTp / SANITARY NO. AI'PI+CARO/ti^BM A DATE
Olyry CRSS_N'AMJ PHONE: Ci CO �0 ' NAA�E L NO: NIC 3 CONTROL#
1 701
ARCHI'I'IiCT/ENG PER: LIC NO: AD19?,Q
L U InAl,
CONr1'ACr,-JJ„,(J �'2.V rryONE:._ QTY. ELE IC PER FEE BUILDING PERMIT INFO
cJLJi,�/ eg/ BLDG ELECT PLUMB MECII
PERMIT ISSUANCE (all ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL �F
ny.Z I hereby affirm that Ism licensed underprovisionso 9
farlear (commencing with 10B DESCRII�I'I/ON
x100 Svclrm7LY10)ot Division 3ofthe Business and PmfcssionsCMc, dmy license is in PANELS
FF--od Ufull foseunder '. � �Q /
FQ-ZW Liccnm ClassS LLicp UPTO200AMPS
vs Q a Ilnm Gmo-nor 201-1000 AMPS
F'zARCHITECTS DECLARATION SQ.FI'.FLOOR AREA $/5;Q.Fr.
ZO,is— IuodemanJ my plans xhell focused us publienecoNs. OVER 1000AMI'S
�<yF-tail SIGNS ELECTRICAL
tY�d; Licensed Professional
yr Q OWNERBUILDERDECLARATION SPECIAL CIRCUIT/MISC.
xci V 1 hereby affirm ma I.m exempt from the Conwcmr's License Law for ma
t 'C3 followingrc.snn.(Section 7031.5,Bosinexamil Professions Code:Any city or county TEMP.METER OR POLE INST.
F < which acquires v permit to construct,alter,improve,demolish,or repair sty structure
Fionm its issuance,also requires theapplic.m forsuch permit to file a signalmdemem POWER DEVICES
Tal C p that he is licensed pursuamuo the provisions of the Contractors License Low(Chapter SWIMMING POOL ELECTRIC
dd mm 9(comancromg with Sectim70001of Division 3 of the Business and Professions Code) VALUATION
m^y onhm he is exempttherefrom and the basis for the ullegOUTLETS-SWITCHES-FIXTURES
cJ exemption.Any violation of
F.Z 4 Section 7031.5 by any applicant for a permit subjects the applieanuo a civil penalty of
q0 not marc than five hundred dollars(ESoo), NEW RESIDENTIALELECIR _SQ.FT.
m—m ElI,asownernfNepmpcny,ormyemployaswithwagesastheirsolecompertsnion. STORIES T'YPF.CONSTRUCTON
a3— will do the work,and the structure is not intended oroffemd forsale(Sec.7044,Business
and Prolessions Craft:The Ccomanor's I.ice im Law does nm apply m an owner of
propenywhobuildsor improves Ncreon,andwhodoessuch work himrelfonhmughhis OCC.GROUP RFS.UNITS
own employees,provided thin such imlrowemenuumum bovalled omTPered hu side.If,
however,the building or improvement is cold within one yearo!completion,theowner- t t
builder will have the burden of proving that he did not build or improve for purpose of TOTAL /n L I II\�
F.
aale.). QTY. PLUMBING PERMIT FGE 'I L 3`'FLO dD+L 4Iw•• .� II YN
❑ T,mownerofthepmpeny,amexclusivelycontractin thlicenredconrauonro
construct the To jet,(Sec.7044,Business and Pro(esai 8 anCode:)'Me Contractor's PERMIT'ISSUANCE � � —
License law doe rent apply Tom owner o f propeny who btu ilds or improve Ncrmn,and
who contracts fursuch projects with a contractors)licensed pursuant m the Contractors
License Law. ALTER-DRAIN&VENT-WATER(PA) ATEI' Y
❑ I vm exempt under Sec. .B&P C 6r this mason BACK FLOW PROTECT.DEVICE Ol/T.IDE
SANITARY YN
Owner Date DRAINS-FLOOR,ROOF,AREA.COND. RECIEIPTp
WORK MAN COMPENSATION DECLARATION SCHOOL TAX Y N
I bembyiffirmthn l have.certificate ofconsant to self-instar,or a cenificamof FlXTURES-PER'BAP RECEIPrk
keri Compensation Insurance or a certified copy thereof(See.38oq LmCJ which PARK FLEE Y N
.ill employee's under this permit GAS-EA.SYSTEM-1 INC. OUTLEI:S RECF.IPTp
Prlicyp �� BUILDING DIVISION FEES
Commit GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cerifedeopyishunbyfomished.
❑ Ccnifiul copy is filed wiN Ne city inspection division. GREASEANDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPINSATION INSURANCE
(This secticoneednm be completed ifthe permit is formse hundroddollars(SIM) SEWER-SANITARY-STORM EA.20)Ft. (ENERGY FEE
�rless.)
I artifytbat in the,perireen.of the work for which this pumit is issued,l shall WATER HEATER W/VENT/ELEC`FR
not employ any person in any manner so as to become subject to the Workers PAID
ComMasationlawsof Califomia. Date WATER SYSTEMUREATING Use R ,, na
ZZ Applicant
Q NOT ICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
(—' y become subject o the Workers Compensation Provisions of the Labor Code,you must
rthwith comply with such provisions or permit shall be deemed mvokcd. BUILDING FEE
forthwith
1 [� CONSTRUCTION LENDING AGENCY SEISMIC R]1 (�
U Z hereby affirm That m
here is u construction lending agency for the performance of
U O me wmk rrr whien mi ernil is firmed(sec.3097,cN,ca TOTAL: ELECTRIC FLEE
Lt. F
Lcndcr.s Numc PLUMBING REE
LerWcri Address QTY. MECHANICALPERMI'1' FEE
U I certify tha aye road d application and auto That the above information is MECHANICAL FEE
coral, lsignor I triply with Il city and county ordinances and state laws relating 10 PERMIT ISSUANCE
huildingconst on.and here y mhodnmpmunmtivesofthisciVioenmrupontbe CONSTRUCTION TAX
U z abovomcmom propeny for penton purinsoa. ALTER OR ADD TO MECH.
( e)ag m save.Inde mify and kap les the City of Cupertino against
Iiabil' Lap mcros,cosu an expenseswhlchr ayim any way accrue against said City AIR HANDLING UNIT(TO I gtXIo CITE)
inc - end ti of 0i
_ AIR HANDLING UNIT(OVER 1(L000 CFM)
ignature,JApp mcror Date EXHAUST HOOD(W/DUC) PAID 3 w4k,_'_
iAZARDOUS MATERIALS DISCLOSURE HEATING UNIT'('TO IMI.IMT)ll'TU) Date Receipt It
Willihea ¢ant or future building occupontamre orbundlchummmusmamrud HEATING UNIT(OVER IW,000 BTU) TOTAL:
defined by the Colander,Municipal Code.Chapter 9.12,and the Health and Safety
as d
Code,Section 25532(a/L` � VENTILATION FAN(SINGLE RESID)
❑Yes / Nl'
/V^� BOILER-COMP(3HP OR 100,00(1 BTU) ISSUANCE DATE
Will theapplicamorf ildingmcupatu.secquipmemrrdcviaswhichemit
ha>eNous air conumin u as def ed b Jul Bay Arm Air Quality Management BOILER-COMP(OVER I WdAlO BTU)
Diarinn4
❑Yk�nmmx
/ NNEW RESIDENTIAL MECH. $Q.FT.
1 have muen Is mama meets un r Chapter 6.95 of the
California II Secti s 255115,25533 an 5534. 1 unJcrsund that
Ifn chuilJ' currentlyhave' anis csq�mibiliry mnotify the
a Pan f n met prior t a an�Certificate of
Ott cy. 61
mhonzcd a6 t Dam TOTAL: ISSUED ar,or
-61-
OFFICE