26531 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RIIILBINli,e"BCrRICAI. PERMITNO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL26531
HUILUIN(I 1'ROSRC'1'IIIRNT'IFICA'I'1XIN
BUILDING ADDRESS: 1 SANITARY NO. APPLICATION SUBMfrI'AL DATE
Q UNIT# LOT It
OWN:RS AME: \\ �(iQyF.: CONTRA Cs,'^Rt'g'NAMuI� LIC NO.�y L61D N/C ��L#
AR_CIII"1 CCT/FNGINI?IiR: LI`C((N6�0: AGU-SSS:` •VR, JD ❑ 7S �
ov Y�Oa l / �tllc,,�ll 41� Sdg q_. I1
CONTACT: L PHONE: r�,s� QTY ELECTRIC PERMIT FEB BUILDING PERMIT INFO
( r� l e U — 136—�p 5� ��� BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
pay I hereby affirm that l am licensed underprovisions ofnVtcr9(commencingwith
u100 Seaiom 71100)of Division 3ofthe Business and Professions Code,and my license is in PANELS
full force and 1 /
tF- effect, nIRI IJP TO 200 AMPS S,6 a f/ W1
a _�_
Fa-Zm( License Cluu Lic.#
co6y Dam Contractor �� 201-1 AMPS
ZOH�' ARCHITECPS DEC TION OVE PS SQ.FT.FLOOR AREA $/SQ.Fr.
0 y,..0 understanJ my plans shall be used us public recoNs.
SIG
QQ� Licensed Professional
K�
a 6OWNER-BNLOCR DECLARATION SP 1 IT/MISC
���dd'OaF 1 hereby affirm that I ern exempt from the Contmetots License Lew for the
I+13�w followingreoson.(Sectinn 7031.5,Business and Professions Craig:Any cirya coumy METER OR POLE INST.
f5�g' which milmon a permit m construct,alter,improve,demolish,or repair any structure
rM3 7 prior to its issuance,also requires the applicant for such pemutto frleasignWamtement DEVICES
¢aj 0 that he is licensed puntom to the Wovisions of the Cantractoes Untrue Law(Chapter
o0' 9(commencing with Section 7000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALppT10N
y or that be is exempttherefrom and the basis for the alleged exemption,Any violation of _"J16
Q Section 7031.S by any applicant for a permit subjects the applicant to a civil OUTLETS-SWITCHES-FIXTURES Icy
Y Y le pp peneltY of �O -� / Q
t mora than five hundred dollars($5(X1), 111
m n❑ I,usowneroDhepropery,armycmplayeeewith wegnmtheinolecompemetian, NEW RESIDENTIAL ELECIR _SQ.PT. I STORMS 'TYPE CONSTRUCTION
y3. will dothcwons Cdtheswcmreisnatintenense La a does not
to anowous
and professions Code:The Caawmon,License law uch not apply to an owner of
own employees,
pdvideri rovestheceon,andwhodoessuch wacdoork roselfonhrough his OCC. RES.UNITS
own employees,provided that such improvements nR not intended oraffcred for sale.If,
however,the
avet a burden
ofementissat ha withiniact builyespd
or improve
for pic urpose f TOTAL: .O
aid .).
will have the buNen of proving that he did not build ser improve for purpose of
ale.).
❑ I,ct the project ec.7(y,em exinss and ontagingwiNlieensed Cargagtorsro QTY. PLUMBING PERMIT F- D ONE APN
construct the project apply
to
Business and Professions CWeprib.
ve Coatm,and PERMIT ISSUANCE \'
License Law dols not apply to an ownero f progeny who builds or improves Nereon,and
wive selmits forsuchprojatswith acontmetor(s)licensed pursuant to the Contnetors ALTER-DRAIN&VENT-WATER(EA
L]all law. ) FEE SUMMARY
❑ I em exempt under Sec. ,B&P C for this moron BACK FLOW PROTECT.DEVICE I ilts
-
SANITARY YN
Owner Dam RECF.IPTp
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,ARCA.COND. SCHOOLTAX Y_N
❑ I hereby affirm that T have a certificate ofcotnent to self-insure,or a cerdficate of RECEIPT#
MIXTURES-PER TRAP
Workers'employmtinnlnsumnce orecenifiW copy therwf(Sec.3g00,LabCJ which PARK FEF. Y N
colics nllemployeeer hi L RECF.IP #
Policy J q GAS-PA.SYSTI:M-I'INC.40UTLEfS - BUILDING DIVISION FEES
Company {
❑ C<nifiedcopy is hcmby famished. GAS-EA.SYSTEM-OVER 4 EA) PLANCHFCK FEC b6.;I'D
❑ Ccrtifiedcopy is filed with the city itnpection divisiao. GREASFANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION ROM WORKERS' GRCASETRAP SOILS FEE
COMPENSATION INSURANCE
(This sectionnmdnot be completed ifthe permit is for one hundred doEm,($IN) SEWER-SANITARY-STORM FA.200FT. ENERGY FEE
mless.)
I rarity that in the performance of Ne work for which Nis permit is issued,T shall WATER HEATER W/VENT/ELF.CTR fj
not employ any person in any manner so as to become subject to the Workers' pp ID
Z
Compenmnlaw
tiosof CWifamia. Data WATER SYSTEMITREATING Date Receipt#
Applicant
Z Q NOTICE TO APPLICANT:If.after making this CeniOcateaf Esemption,youshauld NEW RESIDENTIAL FILMS. SQ.FT. TOTAL:
rA becamesubjecuo the Worker's Compensation provision ofthe labor Code,you must
5^ fnnhwith comply with such provisions or this permit slmll be demand revoked. BUILDINGFEE ZRI
CL, o CONSTRUCTION LENDING AGENCY SEISMIC FEE ,
U Z Thereby hich his
is eeconstruction197,lendingagency for the performance of TOTAL: ELECTRICFEE
L) O Ne work for which this pemut is issued(Sec.309"/,Civ.CJ O'D
w .-t Lender's Name PLUMBING FEE
0 (F.-1t Candor Address - QTY. MECHANICAL PERMIT
1 certify that I have read this application and stem that the above in(omation is
r1" Li) correct.T agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FCP.
building construction,and hereby authorise capresenatives ofthiscity toenmr upon the CONSTRUCTION TAX
L.) ahovemcounned property for inspection purposes. ALTBRORADDTOMECH.
(We) gree to save,indemnify and keep harmless the City of Cupertino against
labilifients,costs and expenses whichmay in any wayaccrue against said City AIR HANDLING UNIT(TO Mai CFM)iciecfthegmmingofthispeAIR HANDLING UNIT(OVER IB,000CFM)uha,
liconl/Contracm���� Data EXHAUSTHOOD(W/DUC) PpE ZIP
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO L00,00)BTU) Data
Will the applicant or form building occupant store or hattdle scandal material HEATING UNIT(OVER 100,000 BTU) TOTAL: ate•
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)'I
11 Yes ❑Na VENTILATION PAN(SINGLB RISIU)
Wilhheribrant.,fourebuildin oeeu BOILER-COMP(3HP 00.100,000 BTU) ISSUANCE DATE
pp g panmseequipmrntardeviceswhichcmit
hazardom air cameraman as defined by the Bay Area Air Quality Management BOILER-COMP(OVER Fill BTU) �V B
Mum?
❑Yes ❑No NEW RESIDENTIAL.MECH.—SQ,PI'. �P2 2 199,0
1 have rand the according,materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that C/
if the bui lding does our ctremly have ranging,that it is my responsibility to notify the lY Ur'• (,
ccupamt of the requirements which must be met prior to issuance of a Certificate of v~thl(�I
Occupancy.
Owner car uohodud a,.[ Data TOTAL: ISSUED BY:
OFFIC