26779 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO APPLICATION/PERMIT PLUMBING.MECHANICAL-nUmDUCAL - PERMIT No.
BUILDING DIVISION26779
„BUILDINGPRO]ECTIBN.N'FIFICATION.-
BUILDINGADDR.SS: �������1�11 I_/ //O SANITARY NO. APPLICATION SUBMITTAL DATE
RtM # LOT# G� ro % ///t.y�
O NAME: CONTRA�TOR'�r E�^ LIC NO: N/C C CCONIROL#L
ARCHITECT/ENGINEER: LIC NO: r-
5�0 P( WooD(;. ❑
CONTACT: PHONE: y` fi i d F 9 i A#.Y 3 3 s q as d€'a�.;
ELECTRIC PHRA l # e ro+,, .7FEE � BUILDING PERMIT[NPO x ` "
S a'r &`T$A gK i'.'7 x x a BLDG ELECT PLUMB MF.CH
PERMIT ISSUANCE ❑ ❑ -❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JO CRI
pw2, I hereby affirm that l am licensed underpmvlsionsof ChVter9(commentingwith
EW
FJOO Section 7000)of Division 3 ofthe Business and Professions Code,and my license is in PANELS
Wfull force and effect
y� License Class Lic.# UP TO 200 AMPS
y R d Dam Comment, 201-I"AMPS
R O h Z ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
0Z—= I undermnnns d my plashall be used as public records.
= JSIGNS ELECTRICAL
yy -�
Licensed Professional
y�Q
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
�OC' 1 hereby affirm tbd 1 nm exempt from the Contractor,Co License Law for the
(x131+-rn following reason.(Section 71031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
f5Owhich requires a permit to constrict,elrer,improve,demolish,of repair any smtedmid
C�Q:Frt
prioo its issuance,also requires the applicant for such permn,file le a signed statement POWER DEVICES -
µl LL O O that he is licensed pursuant to the provisions of the Centmdor's License Law(Ch tmac
d 9(commencin th Section f Division 3 of the Business and Professions Code SWIMMING POOL ELECTRIC
4p�+' (commencing )o ) VALUATION
XWF,may or that he is exempt therefrom and the basis for the alleged exemption.Any violation of
❑ a Sectoo
n]03L51, any applicam for a permit subjects the applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES \ /n �. 7. D INJ
�j y0 not more than five hundred dollars($500). NEWRESIDENTIALELECTR _SQ.FT -1
p� L ❑ I,Asowrk,and epsonart,ormycmployedorofwegesasthe(Son 7011 mdov, '\ �9TORIBS'n` OTYPE CO STRUCTION
0.3� will dmhewons and the she Contractor's
License
rmorntapply tflan,Business �•�, C II``IIVV�prO I� 1�i�1;
and Professions Cale:The Comractors rad eche Low does not apply lf an rough of
propertywhnbuildsorimpmvesch improve entswessuchwork oroffredthrougM1 his n
ownemployees,provided preachimprovementserenot intendedmoffered Ihe.forsaide.If, FAT RE�.UNITS
however.ilder%the ave the orimprovementissoldedidnot year or improve for thrower TOTAL. --r
sae.). will have the burden of Froving that he did not build or improve for purpose of
sola] m.._.X# y s u s.. . . 4y s
❑ i,as owner at wnexdus velywnmaonngwuhllcensedcontrado t Qom.pi:aU ,#' PLUMBING PERMIT; *M9^� sI PEE,a NhOOD ZONE APN
onsuuct the project(Sec.IIW4,Business and Professions Code)The Connrmcmrs - § `a
License Law does not apply loanownerofpropeny whobuildsorimprves thereon,and PERMIT ISSUANCE
who contends forsuchp jells with amantmctons)licensed Forstmann,the Contimlore
License Law. ALTER-DRAIN&VENT-WATER IIA) . a�y FCE,SUMMARY
❑ I um exempt under Sec. B&P C For this reason BACK FLOW PROTECT.DEVICE y f U'TSIDL :ES
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ I hereby affirm that l have a certificate ofconsent to self-insure,or a cenificmeef RECEIPT#
FIXTURES-PER TRAP
Workws'Compensatlon Insurance oracertified wpy thereof(See,3g00,Inb CJwhioh PARKFEE YN
covers all employee's under this permit. GAS�EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCIIECK FEE
❑ Certified copy is hereby Famished.
❑ Certified copy is fled with Ne city inspection divieioa GREASEANDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION PROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not he completed ifthepprout is for one hundred dollars($1(b0) SEWER-SANITARY-STORM F.A.200F1'. ENERGY FF.H
or loss.)
I certify that in the performance of Ne work for which this permit is noted,I shall WATER I IFATER W/VENT/F.LECTR s
not employ any Ferson in any mammy so es n,became subject m the WorkersPAID
Compensation Lowsof California. Date WATER SYSTENUTREATING Date Receipt#
Q z Applicant
O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,youshould NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
Hbecome subject to the Workers Compensation Provisions ofthe labor Code,you must
forthwith comply with su It provisions in this permit sholl be deemed revoked. BUILDING FEF.
�] CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz I hereby affirm thanhem is m conshundred lending agency for the performance of
O the work for which this permit is issued(Sec.31097,Civ.C.) TOTAL: ELECTRIC FEE
Lenders Name
Lis Lenders Address QTTI' 4s 'I )'MHCIit�NICQLr PERMIT +; 5€p k f PLUMBING FEE
PEE 4
V 1 certify that 1 have read this application and slate that the above information is #° &*1" " `V's
correct I agree to comply with all city and county ordinances and state lawsrelarm,to PERMIT ISSUANCE MECHANICAL FEE
building construction,and hereby authorize representatives ofthis city to automation,the
V above-mentioned property for inspection purposes. ALTGR OR ADD TO MF.CH. CONSTRUCIONTAX
(We)agree m save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,cn"and ex swhich yin anyway accruemgainstsaid City AIRIIANDLINGUNIT(TOUtodoc M)
inconseque c fine anting of h emit.
AIR HANDLING UNIT(OVER 10.000CFM)
.ignatureofAph inCorencmr m EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE T HEATING UNIT(TO 100,030 BTU) Dam Receipt#
Willme appliczmor future building occupant store or handle hamrdous material HEATING UNIT(OVER 100,000 BTU) T
as defined by the Conanine Municipal Code,Chapter 9.12,and the Health and Safety
Code,section 25532(e)1
❑ VENTILATION FAN(SINGLE REBID)
255 El No
Will the a licamorfuwrebuildin BOILER-COMP(3HPOR IUO,WO BTU)
ISSUANCE DATE
Fp goccupantusceyuipmentur devices whichemit , p�
hamrtlona air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) � � B ly
District?
11 Yes El No NEW RESIDENTIAL MECH.—SQ.PI'.
1 have read the hazardous materials requirements under Chapter fi.95 of the ^�u` 2 p 1994
California Health&Safety Code,Sections 25505,25533 and 25534. I understand than
if the building does not currently have a tenant.that it is my responsibility to nctify the
occupam of the requirements winch mural be mu prior m Issuance of a Certificate G1-1,yuv ur IN TI
ccupancy.
Owner m amboiixed aged DaleISSUED BY:
OFFICT-