26794 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUILDINU-LLRLMICA I PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. 26794
BUILDING.DIVISION IIUILUING PROJECT IDRNfIF'ICAT117N
BUILDING ADDRESS: ((fix.-/�, p 1I/� SANITARY NO. APPLICATION SUBMITTAL DATE
�� V e UNIT# LOTH
OWNIi NAMIi: HONE: COMfR CTO 'S Ah]{iy�,� /� LI O
•Vl /V/ (�h. NIC CGNI'RGL»
ARCHI iCT/ENG LIC NO: ADD S' / e( N
CONTACT: PHONE: QTY, ELECTRIC PERMIT' FEET BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE E] M
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL JOB SCRITJON
Matz I hereby afflnn that l an licameduaderprovisioasofChapter9(commencing with 1 �C'�'�ro`
�
000 Section 7030).f Division Sof the Bminessnonm
nd Professions Cede,and any,[Iran.is in PANELS 6///
at�F full morard effect.
4z WU� I.Ear.Class Lic.It UPT02MAMP5
y<y Date Contractor 201-]"AMPS SQ. .FLOOR AREA $/SQ.FT.
ZOrna ARCHITECT'S DECLARATION OVER IWill AMPS
O Z-' I understand my plans shall be mud as public maims.
1:-vs 1=� SIGNS ELECTRICAL
qq��dd .4 Licensed Professional L 4� 11"'t,
� --'
Lp; 6 OWNIiR-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. _
KOi, 1 hereby affirm that 1 am exempt from the Contractor's License law far the V. F-1 NI
673 LL ao following....(Suri..7071.5,funmass and Roressions Code:Any airy or county TEMP.METER OR POLE.INST.
sl-)�; which reqPermit requires a Peo Cnnsuua,at ler,improve,demolish,or repair any structure
�f pri.rmiu iasuuc<,ulsurcquircathe applicant for each Merit..filensigned nem mem /
POWER DEVICES 1
_p 0z that he is licensed pursuant to the provisioner of the Contractors Licente Law larger na
n eLL 9(commencing with Section 7")of Division 3 ofthe Business and Professions Cade) SWIMMING POOL ELECTRIC ^�c 2
or that he is esempuherefmm and the basis for thealleged[sere tion.Any violadonor OUTLETS-SWITCHES-FlJ(TIIRFS !AG Y'
t.4a S[ctionT03L5by.yapplicamforepesmitsubjemtheappli.n ,.ncivil,e ryof
M nil mom than ftvc hundraddullars($500). NCW RESIDENTIAL ELECfR5 .FT.
❑ I,nenwnernfthcpropcny,ormyemployees wiNwegcs uthcirsolecompcn.tiun. Q STORIES TYPE CONSTRUCTION
L _ will dvrhelim,aced Ne no
License
does
not SttAf1an Bus
and Professions Cmle:The Ces thenors License Lew does not apply lf rt owner of
who
pmpevtyloyms,mvid rap t.sucM1impmandwts mssuch tintcMkoroffe.rah We.sugh hf, OCC.GROUP RES.UNITS
howownever,
fyreap ingori that vemenpmv sold
wit are notyearo d mpletion,theown If,
however,Ne have
the orimpm proving
is sold wiNin one year ofc prove f r thepose of
builder will have Ne numen of n that he did not build tiro rove for TOTAL"
pmvi g P purpose of
ale.).
❑ I,u.wnernfNc pmpeny,amexclusivelyc.nuacting with licensedconntuctorsm QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
smou the project(Sec.70,14,Business and ra
Pfesrima Code:)The Contractor's
Lmicense Lawdoes nota I to an ownerof n hobuildsorim PERMIT ISSUANCE ..11
PPY prop[ yw pmvi Narcon,and .2 V
conarsam a Law.foreuch pmjecu with aconvtcurts7licemed pursuenuodote Conweror'a
Licence Law. ALTER-DRAIN @VENT-WATER(EA) FEE SUMMARY
❑ I am exempt antler Sec. ,B&I'C for this reason BACK FLOW PROTECT.DEVICE. OURSIDEFELS
SANITARY Y_N
Owner Dam RECEIPT#
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMI'1?NSATIONOECIARATION SCHOOI.'fAX YN
❑Workers'
Comsuffpensation
NaUhave
opeor a cru of cmeent copyth ssal'Snsurc,m aceC.)whichficapeof RECF.IPI'»
MIXTURES-PER TRAP
Workers Cnmpensetion lrnomnce.rtcenifieq copy Nercofl$tt.78110,Lab C.)which PARK FRE YN
covers all employee's under Nis permit. GAS-EA.SYSTEM-1 INC. OUTLETS RECEIPT#
Policy» BUILDING DIVISION FEES
Cram C ri fed copy Is hereby famished, GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
$Ccni
❑ Certil7W copy is fled with the city inspemi.n division GREASR4NDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTILICATC OF EXEMPTION FROM WORKERS' GREAS17 TRAP SOILS FEF.
COMPENSATION INSURANCE
(This aectianneednm becompleted if Ne permit is for oas hundreddollm($100) SEWER-SANITARY-STORM EA.200FT. -(�Q ENERGY FEE
or less.)
I cenify that in the performance.fthe work for which this Permit is issued.I shall WATER HEATER W/VENT/ELECI'R
not employ any penin in my manner so u to become subject to the WorkersPAID
Compearation Lewsof Califomia. Date WATER SYSTEMfTREATING Dam Receipt#
p z Applicant
z C) NOTICE TO APPLICANT:If.after making this Cerificac of Exemption.you should NEW RESIDENTIAL FILMS. SQ.Ff. TOTAL:
Fy become subject to the Workers Comprnsadon provisions of the Laden Cale,you must
a ; forthwith comply with such provisions or permit shall be deemW revoked. BUILDING GEE
0. CONSTRUCTION LENDING AGENCY SEISMIC F'EE
p Z I hereby affirm that them is a construction lending agency for Ne performance of
U C) the work for which Nis permit is issued(Seo.3097.Civ.C.) TOTAL: O ELECTRIC FEE
p Lamb,',Name
Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE .0
U I cenify that 1 have read this application and state that the above information is
correct.la agree mcom I ry g MECHANICAL FEF.
g pat wrehysuirymW wan ominences and sate lawsrelpon m PERMIT ISSUANCE
L) 7 movengconrwcdomand hart hyauNoriur[pusenmdvcsof Niscity menterupon the CONSTRUCTION TAX
U ebnve-m[nt gree Property far and keep
ALTER OR ADD TO MECB.
(Wc)agree to save,indemnify and keep harmless the City of Cupertino against
liabiliue urince enu,com
and Cape
awhich mayinany woy azcme againiauitiCity AIR HANDLING UNIT(TO 10,000 CFM) L ��
mcom ohne gunlmg.f at trait.
AIR HANDLING UNIT(OVER IO.IXN)CFM)
Signstumn Appt / omtruc r a EXHAUST HOOD(W/DUC I O�
PAID O
HAZAR US MATERIALS DISCLOSURE HEATING UNIT(TO IIXI,IXp BTU) Dae Receipt It
Will the applicant or future building occupant same or handle haumous material IIEATING UNIT(OVER I(Xl,fllxl BTU
as defined by the Cupertino Municipal Code,Chapter 9.12,end the Health and Safety ) TOTAL:
Code,Section 25532pd?
Cl Yes 13 No VENTILATION PAN(SINGLE RESID)
Will the upplicansorfntu,building«cupantuucquipmrnmrdevica whichemif BOILER-COMP(311P OR 1N,"BTU) ISSUANCE DATE
monition,air ronuminams as d[fimd by the Bay Ates Air Quality Management BOILER-COMP(OVER 600,000 BTU)
Uisvicr7 .
❑Yee ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have read the hazardous materials requirements undo Chapter 6.95 of the JUL 27 1994
California Health&Safety Code,Sections 25505.25533 and 25534. 1 understand that
if the building does not currently have n tenant,that it is my responsibility to notify Ne /.
occupant of the requirements which most he met prim to issuance of a Certificate of CI 1 Y ul- Lut-rfl l ByIJ
Oconpnncy.
Owner ortmhodzM ager, Data TOTAL: ISSUED BY:
OFFICE