26148 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUIL)I G-ELEUDU AL I'ERMI'fNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL /�C .$ 4$
4
BUILDING DIVISION BUILDINO PROJECT'IDENTIFICATION L o 1
BUILDING ADDRESS: C SANITARY NO, APPLICATION SUBMITTAL DATE
11eq LF
6 I \] /1(�L UNIT# L09'#
OW NAME: HONE: CONTRA '. NAME: LIC NO:
VIC
. CONTROL*
El
^O
"CHULCUEGADDRESS:
CONTACT: PHONEQTY. ELECTRIC PERMIT FEE BULDINGPUVI T I `5
BLDG ELECT PLUMB MECH
st PERMITISSUANCE
LICENSEDthCOMRAGTORSDECIARATION A LI P_S-RESIDENTIAL_ BDJEGRl N
pyZ T 7000)ereby ufNmlbm l 3 of the
planne,bad Preed under ofessions Cmh,9(commearclar,cense with
t`1 W O full fi n OOflo)of ecivixinn 3 of the Business and Professions Cotle,and my license Is in p NE T
< Up full Tore can.)effect. ;—
<
II 'I\Vt
QZumI License Clue Lic.N PTO /I
y=y Date Commetnr H.1 Sr ,'�� 5
Z�yZ ARCHITECTS DECLARATION VER IOW AMPS i!� _ _o ' I Q FT.FLOOR REA 5/SQ.Mr.
I understand my plans shall be used u public records. /�,[,
OZ^I!!I''���� s.(�1a� " r 1 y /11fG
Q^�j I.icenud Professional IGNS EL �ICCI. s W- .I,a�e _1-� L�.r/ L
LOU I hereby mffnn 0 WI emR a sopa Eon Ei<ConlmcmN'e License Law for the SPECIAL CIRNIT/A115C, i,(od `I t�,sk
473
on following remon.(Section 7031.5,Busineumd Hafessions CMi:Anycityorcounry TEMP.METER OR POLE INST. s'`V
so
1 which requires a permit to consumer.alter,impose,demolish,or repair any structure
t`unIY:E prior to its issnurwe,hom,im,the applicant for such permit to file a signed alinement POWER DEVICES
y�j IK Q O thm he is licensed pursunot a the provisions of the Contractor's License Low(Chapter
4 0X 9(csanmencing with Seclion01)(k0of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUA'/11�0-N/�
_y onhnt he is exempt thvrcfrom and the hnsie fonhe vlleged exemption.Any violation of OUTLETS-SWITCIIFS-FIXTDEUS
1$=Z G Seci 315 by mY applicant fora perma subjects Ne npplicanno a civil penalty of .7 11
dVd1,h.'0wmk.mmI
nave hundred dollun($SW). NEW RESIDENTIAL.ELECTR _SQ.Ff.nrepruperty,army employeeswith wugcsnstheiraolecompcnsatinn, STORIES TYPE CONS'fRUCT10N
teswctme is not imendedorofferd for sale(See.1144,Business
ons Code:'Me Contractor's License Luw does nm apply to un owner of
builds or improves thereon and whodoessuch work hinnelforthrough his OCC GROUT' RES.UNITS
own employees,provided Nmauchimprovememsvenot imendeduroffereJ forsWe.If.
however,the buildingor improvement is sold within one year ofcompledon,theowner- TO builder will have the burden of proving that he did not build or improve for purpose of
01
sale.).
❑ I,asownerofthepmpeny,amexclnsivelycnntmetingwithlicensMmntmctorsm QTY: PLUMBING PERMIT - FCC FLOOD ZONE APN
construct Ne project(See.](004,Business and Professions Core;)'no Contractor's PERMIT ISSUANCI?
License Law Joe,nol apply manownerofpmpeny whmbuildsorimprown lhereon.and
who contmets mrsuch projema with aenmrstrain)licensed pursuant to the Contractor's AIA FR (EA)
License Law. FEE SUMMARY
❑ I em exempt under Sec. - B&P C for this rtuon BACK FLOW PROTECT.DEVICE SANITARY Y 1 FF N
Owner Dam DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
I hereby uffum thin 1 hove a cenifeate of consem m self-inaurc,or a cenificme of RECHIPT p
�erkerfi Compenseliun insurance ornartifiul ropy aherrof(Sec.3600,Lub CJwhich FIXTURESPER q'RAP PARK FE
di YN
covers all employees under permit. GAS-EA.SYSTEM-I INC.4 OUTLETS REI .PT
pal toy# BUILDIBGDIVIS FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCII PICK PEE
❑ Certified copy is hereby furnished.
❑ Certified copy is Bled with the city inspection division. GRRAMVINDUSTRL WASTE INTERCEPTOR GRADING Do. r�
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS IF
COMPENSATION INSURANCE f
(This section need not becompleted if Ne permit is forome hundred dollars($IW) SEWER-SANITARY-5q'ORM HA.200FT. ENE .Y FEF.
or less.)
I certify that in the performance of the work for which this permit is issued,I shall WATER HEATER W/VENT/ELECTR
Na employ any person in my m as m become subject to Ne Workers' PAID
COmpensmm.Lawsof California. Date so WATER SYSTEM/TREATING Dae Recto #
Z n NOTICE TO APPLICANT:IL after makingthis Cedificme of Exemplion,you should IsEW REST DENTIAL PLM B. SQ.FT.
All.
lA becameh comply
the Workers Compensation ermi,iomoftheemed Care,you man
forthwithcomply with such provisions or ptlmil shell be deemed revoked. BUILDING FEE
w CONSTRUCTION LENDING AGENCY SEISMIC FEE
z
✓✓C Iherehy affirm that hem is u construction lending agency for the performance of
[) O the work for which his permit is issued(See 3097,Civ.C.) TOTAL: F EMIUCFEE
Leader's Name
U Lender's Address QTY. s MECHANICAL PERMIT, FET? PLUMBING FEE
1 certify t!...1 have read,his applicmimr wd same that the above information is '
�" 4 correct. (agree to comply wish Vl city and county ordinances anJaum laws reletingm PERMIT ISSUANCE MECHANICAL FEE
,,0 building construction,and hereby authorize representatives ofthis city mener upon the CONSTRUCTION TAX
L) Z alsovomvmiorsd property for inspection Purposes. AL'I'BE OR ADD'TO MECII.
(We)agree to save,indemnify and keep horn Ne Ciry of Cupeat o agoinsl
liabilititaijudgt costsnndexpenses 'ch mywayaccrueagu' said Ciry AIR HANDLING UNrf(TO 10f00CFM)
I.zryroft gra oRhls pe
6 AIR HANDLING UNIT(OVER 10.000 CFM)
Sig rare of Applicml/Contrucmr Doti F.XIIAUSTIIOOD(W/DUC1)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATINGUNIT(TO 100,00011TU) Dane qu,#
Will the applicant or future building occupura store or handle hazardous material HEATING UNIT(OVER 100,000 BTU) T
u defined by the Cupertino Municipal Cade,Chapter 9.12,and are Months and Safety
Code,Section 0)7
11yi,s ❑No
VENTILATION FAN(SINGLE RESID)
Yes
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
WilHheopplicamorfmain building occupant useequipmem ardevicu whichcmit A
rtar ous air commutation u defined by file Buy Area Air Quality Management BOILER-COMP(OVER 1110,000 BTU) P `
strict? 13Yea ❑No NEW RESIDENTIAL MECH.—SQ.F1f. JUN sR O
1 have read the harardous materials requirements under Chapter 6.95 of the ygg�
if the ail ingfledhs .,etyrues Coca,Sermons25505,25533 roodspaira 1undeNmdthin
ifthcarrilo the resnmments which
investment, bormiresponsibilitytonmifYthe Ur. �'LrLU
c ata i of the requiremems whicM1 must be met prim m issuance of a Cenifcme of tHllN
aeeapaner.
Owner c r aehudzed agent Dale TOTAL: ISSUED BY:
OFFICE