26915 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO .ITU RTCA1. PEER r NO.
APPLICATIONIPERMIT PLUMBING-MECHANICAL.
BUILDING DIVISION BUILDING PNOJEC'I'IIIEN'fINICAT1fIN 26915
BUILDING ADDRESS: SANITARY NO, AP1PLICATION SUBMHTAI.DA'IR
<7�3
• • J
v UNIT# LOT a�
O S� AME: PHONE CO R'S NA LIC NO:
NIC CONTROL p
ARCHIVE 't iNGWE... LIC NO: A DR Is / ❑
CONTACT: PHONC: e �_r' ADI
QIY €§- 5�j'ELECTRIC PERMIT FEE BUILDING PERMIT INFO
- -A' I - BLDG ELECTLUMB MECH
PERMIT ISSUANCE El
CENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
�yy Ihcrel,wElmtitm lam licensed underpmvisionsof Chapmr9(commencing with
OO Section 71)(0)of Division 3 of the Business and Prnfessions Code,and my license is in PANELS
yzw full LimomeanJ �e
FZu, Licence Clas LIC.# UPT0200 AMPS
w=y Date Contractor �� 201.1000 AMPS
ZOya ARCHITECTS DECLARATION OVER ICfq AMPS SQ.FT.FLOOR AREA $/SQ.Ff.
Ozal Iundersmnd myplans shell bcused as public records. IV
ryl=u1 I SIGNS ELECIRICgL
Q f J Licensed Professional
ed WCQ OWNER-BUILDER DECLARATION SPECIA CUIT/MISC.
XOaF I hereby affirm that I um exempt from the Commences License Law for the
cc "161 following ancon,(Section 7011.5,Business and Professions Code:Any illicit, y MP.METERO ST.
��; which rarylres a permit to construct.alter,improve,demolish,or repair anyawcwre
p-2 prior to its issuance.also re,doce Omapplicam fsrsoch pmota,file a sign ed cumme POWER DEV
u) Op that he is licensed pursuentto the Provisions ofthe Comment License Law(Chapter
6-XN 9fcourmencingwith 5ution]IKKgof Divisianlo(Ihe Busineuand Rafessions Code) S 1 NG POOL ELE I VALUATION
WM, or that he is excmpuhetefmmvnJ the bazis for the alleged cxemptinn.Any violation of -S E$-FI
GSection 9031.5 tin any applicant for a permit subjects the applicant to aaivil penalty of
C not more than Eve hundred dollar,($500). NE IDENTIAL F.LhCTR —S .Fr.
m ❑ I,usowneroftheproperty,ormyemployees with wages astheirsolecompensation, Q STORIES TYPE CONSTRUCTION
L will do the work,and the stmerure isnot intended proffered forsale(See.]044,Business
and Professions Cale:The Cannot License Low does not apply to an owner of
property who builds m improves themon,and who dote such work himself or through his
ownemployces,provided that such improvermntsarenot imendcomaderedirawle.if, OCC.GROUP RES.UNITS
however,the building or improvement is sold within one year of completion,theowner,
vin that he AiJ nm build or int rove for TOTAL:
pro g P purpose of
sale J. '. v
❑ I,asown<rofthepropeny,emexdueivelycnnheering withlicenad contractorsm QTY�x' � PLUMBING PERMIT FEL; FLOOD ZONE APN
consumer the pmjmt(Sec.7044,Business and Professions Codc:)The Contractor's
License lawdoes not opplylo m ownerof property who builds or improves therwn,end PERMIT ISSUANCE
whocamraas(or such projects with ammusesor(s)licensed innocent in the Contractor's
License Lit, ALTER-DRAIN&VENT-WATER(EA) " .[T:E SUMMARY
❑ I am exempt under Sec. ,B&P C for this reason
BACK FLOW PROTECT.DEVICE. z T U:FEES
SANITARY YN
Owner Date DRAINS-FlAOR,ROOF,AREA.COND. RECEIPrN
WORKMAN COMPENSATION OF.CfARAT10N SCHOOL TAX YN
�l herchyaffirm that l haveucertificate ofconsem to self-insure,or a cenificate of FlX'1'URCS-PF.R TRAP REC[IPI'#
Worked Compensation Insurance nrecerti0ed copy therwf(Sec.3g0o,LOC.)which PARK M1 Y_N
rovers all empinyeejuudee ibis irfrrpi��C.^ ^� GAS-EA SYSTEM-I INC.4OUTLETS RUCEIPTM
Polley# BUILDING DIVISION FIi11S
Qnmpony -— - - i - — — GAS-EA.SYSTEM-OVER 4 HDO PLANCHECK FEF.
❑ Cedifieduse isherMyfumished.
�I Codified copy,is filed with the city inspection division. GREASFONDUSTRL WASTE INTERCEPTOR GRADING ME
�C CERTIFICATE 017 EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This action modnot be completed if Ne permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200F1'. ENERGY PER
ar leas.)
I ocnify that in the performance of the work for which this Permit is issued,l shall ' WATER HEATER W/VENI'/ELECIR
nm employ any person in any maturer ao as m become subject m Ne Workers' PAID
Compensation Laws of California. Date WATER SYSTENVTREATINO Date Receipt#
Q z Applicant
z 0 NOTICE TO APPLICANT:If,aftermaking this Cenificme of Exemption,youshmdl NEW RESIDENTIAL PLMB. SQ,Fr. TOTAL:
I•-' 4 become subject to the Workers Compensation Provisions ofthe Lade Code,you must
� > fonhwith comply withsuch provisionsm this permitshdl be deemed nevokcd. BUILDING HE
W
z CONSTRUCTION LENDING AGENCY SEISMIC FEE
^a I hereby affirm that there is a construction lending agency for the performance of
U O The work for which this permit is issued(Sm.3W7,Civ.C.) TOTAL: ELECTRIC FEB
Lts 6Lender's Name e PLUMBING EEE
0 Lender.Address QTY. - .MECHANICAL PERMIT FEE
1 cenify that I have need this application end stem that the above information is
correct I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
building construction,and hereby authorive re reseni tivesof this city to enter upon the
V 7 abova-mcnliuncdprnpenyhorinspcc' mp.es, ALTER OR ADD TO MECII. CONS'I'RIJCTION TAX
C7 (We)ugam no,
, elm wd k p harmless the City of Cupertino against
Iiabilities,jLJgm sponse Inch may inanyway accrue against sai City AIR HANDLING UNIT(TO 10,0010 CFM)
in int pop oftb' rat
t.
J AIR HANDUNGUNIT(OVPR 10,WCFM)
SI antro AI Contractor 194
EXHAUST]IOOD(W/DUCT9
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,11UI)BTU) Date Receipt#
Wills applicmtor future building occupant smut or handle hmnrdaus material
as defined byline Calendar,Municipal Code.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER I00.000 BTU) T
11Yes El No L:
Code.9ecti 25532(¢)] VENTB.ATION FAN(SINGLE.RHSID)
❑
Lot
nI$SWI�C�ATE
Will thea licvnme[umrehuildin cu ruse BOLLEN-COMP(3HP ON IW,BIIO BTU) GG'' PlC4
pp gtb Pan {ea Air touality Mare hemi,
heeadous air contaminants as Defined by the Bay Arca Air Quality Management
Ontario? BOILER-COME(OVER 100,000 BTU)
13 Yea C3No NEW RESIDENTIAL MECH.—SQ.Ff. `JAN 261995
1 hove mad the hamrJnus materials cots under Chapter 6.95 of the /1C
California l lealth&Sur er CMe,Serio 550 5533 and35534. 1 undemtendthm ',n I'I'� VI V IIJ CHI INfI
ifthe in togdoes m hav ten , hatitismyresponsibilitytonoofythe V
occupant of tin iarw ie mus met prior to issuance of a Cenifi a of
Occup
Ow Dnt 'TOTAL: ISSUED BY:
OFFICE