26920 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING-ELRI AI, PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL TI !�6 O
BUILDING DIVISION BUILDING PROJECT'IDENFICATION G v
BUILDING ADDRESS SANITARY NO. APP/PLICATION SUBMITTALL,DATE:
2 UNIT LOT# Cp
RRS NAME: PU0jRACEQRS NAME: LIC NO: V
�vQ4)dNtk nS;XSIA'r�DNG 13�7(ol`jU p� +tlQcil>RC1CI1 , y12 4 N/C CON TRUN,#
\RCHI'I'ECgPNGINEER: - LICNO: HESS:
l3Z(S rc ccC-k.Gt, Cv no GLS
CONTACT: PHONE:
QTY. ELECTRIC PERMIT EEE BUILDING PERMIT INFO
B#NIL,.D��G ELECT PLUMB MF.CH
PERMIT ISSUANCE 11 �f'
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
Metz I heebyoffirm Nat lam licensedmuler panow,mnaofCTapmr9(commenct,with JOB DESCRIPTION
�q00 Sectors.T0110)of Diviaion3ol me Business and Professional Code,and mylicemeie in MANGES �S �
C full force and effect. S
FZw License Class Lic.N IIP T02W AMPS
N 6 y Dae Coneraceor 201-1000 AMPS SQ.Ff.FLOOR AREA $/SQ.lel'.
Fyz�
ARCHITECTS DECLARATION OVER 1000 AMPS
1 understand my plana obeli M oseJ as public rcconks. `Oa
C z_o LSC N/I.11�7\
SIGNS ELECTRICAL Licensed Professional
Oit I and exempt to.ER DECLARATION SPECIAL CIRCUIT/MISC.
d Oa V 1 hereby affirm that I am exempt Fran me Convaetnr's License Law for the
y)30.y following.,,asa permit
toco31.5.Business and Professionsh,le:Any city orcoumy TEMP.METER OR POIF.INST.
Fp�O� which to its
an permit to gimes the mplic improve,such permit
t,ore a signed
any structure
2W}� pnmrmilc iasuanec,also requires the applicant For such permit to fileenigned alatement POWER DEVICES
,W<O that he is licensed pursuant to the provisions ofthe Convenor's License law(Chapter
et e� 9(commencing with Section 7000)of Division 3ofthe Businesimd Pmfesaione Cade) SWIMMING POOL ELECTRIC VALUATION
or that he is exempt herefront and the basis for the alleged exemption.Any 4immlmro of
�zG Section'/031.5 by any applicant fora permit subjects the applicant m u civil penalty of OU'I'hBTS-SWITCHGS-PIXTURfiS
mol mart than five hundred dollaa($500). NEW RESIDENTIAL F.LIiCTR S FT.
50 ❑ I,uaownmaf Neprnpenysrmy employees wiehwagesmtheirsolecompensxtion, Q STORI' TYPECONSTRUCITON
y m will it.the work,and lhestrnalmaix not imandedmnlfered for suk(Sec.90LI Business
and Professions Code:The Contractor's License law does nM apply to an owner of
,Ta,my ohs buildemimpmveathereon,bad whodaessvch work himeelforthroughhia OCC.GROUP RES.ON[PS
awnom Imeco,provideddid such improvements are not intern doroffnol formic.If,
however.the building or improvement is sold within one yearofcompletio t,the ownef- T '
builder will have the burden o'proving that he did not build or improve for purpose of 6-5
Jule.).
❑ Lasowner aftbc propcny,amexclu.dvcly contracting with licensed eontrectora to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the pmjea(Sce.TOM),Business and Professions Code:)The Conwears
License law does not apply toommenerofpropeny who buildser impasses thereon,and PERMIT ISSUANCE If
who contracts for such prob Is with ucoulreamds)licensed pursuant to the Canlmmnrs
License Law. ALI HR-DRAINA,VEN -W CR(EA) ITEESUMMARY
❑ I am exempt under Sec. ,B&P C for this reason BACK RTE
OW PROCT. E OUTSIDE FEES
SANITARY Y N
Omer [);anRECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOIt,R v RP.A,C SCHOOLTAX Y N
-e ]e lhcmhy emtm thmlhavearenificam ofconsemmulGinsurc.ore certificateof FIXTURE$-PER TRAP - RECF.IPP#
erkeri Compensation Insurance or a certified copy radical.(Sec.3800,Latin C.)which PARK IEE Y N
t n all employee a under this permit. GAS-EA.SYSTEM-1 INC.6 U' Eh F.Clil '#
Pull,It BUI DI ,'ION FEES
Company GAS-FA.SYSTEM-OVER4( PfANCHECKF .
ElCenifed copy is hereby famished.
❑ CeniOed copy is file)with the city impaction Division. GREASEITNDUSTRL WASTE I ?RCF: GRADING rE �,
C17R'I IITCATE OF EXEMPTION FROM WORKERS' GREASETRAP IF SOILS Pt
'1 COMPENSA'T'ION INSURANCE
th V
Mois section need not becompletediftheperin isformuldindraddollas($IW) SEWER-SANITARY-STORM It 200Ff. ENEEGY FE,
mleas.)
I certify that in the performance of the work for which this permit is issued,I shall WATER HEATER W/VF.NT/CLECTR
nal employ any px,,,on in any m as r become subject to the Workers' PAID
Compematiou Lawaof Califomia. Date so WATER SYSTUMTREATING U R.\dN
O ,Z Applicant
z7C) NOTICETO APPLICANT:I La flat making this Cenificuteof Exemption, .to should NEW RESIDI'NTIAL PLMB. SQ,IT. 1'O'fAL:
P ^ becomesubjen to the Worker's Coa,mandoa provisions of the labor Cale,you muss
ai 7 forthwith comply with such provisions oat this permit shall be deemed invokedPE". BUILDING -/
4L1 CONSTRUCTION LENDING AGENCY SIi1SMIC
F Q I hereby affimn that them is a conawnion lending agency for the performance of
U O the weak for which this permit is valued(St 3(19],Civ.CJ L ELF CFE: I
V. Lenders Name
Landers Addres, QTY. MECHANICAL PERMIT EEE PLA E13
U 1 coni fy that 1 have mad this applicaion and more that the above information is
W correct. l agree to comply with all city and county ordinances unit slate laws reining to PERMIT ISSUANCE MECHANICAL FE
ybuildingconnonoinn•tmd hereby authori.erepreaentativesof thus city,,enter afraie
V Z moss-aentioned prepeny,for institution Indian.. ALTER OR ADD TO MECI. CONSTRUCTION AX
(Wc)agree to save,indemnify and keep harmless the City of Cupertino against
Iiabilirics,judgmenLs,cases and expenses whichmay in my way accrue against said City, AIR HANDLING UNIT(TO HL"CFM)
on eyuence of the gmnling of mix permit �.
r'
G �SAIR HANDLING UNIT(OVER 10.004)CFM)
.pudda a Appliemt/Contract f m EXHAUST HOOD W/DUCO
•rnlD
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO I110,000 BTU) I Ru.
Will the applicant or
or Gaonbuilding rd,Caperre o,and
Matto asmaterial
as defined by the Cupertino Municipal Cale,Chapter Y.12,anJ the Ilenhh and Safety HEATING UNIT(OVER I00,000 01'U) TOTAL:
Cade,Section 25532(a)?"
13 Yes ❑Not VENTILATION PAN(SINGLE RfSID)
Will Iheepplicenmrfumrcbailding acvpam useequipmcm ordeviceswhich emit
BOILER-COMP( HPOR100,0(gI PTU) ISSUANC DATE
azardom air atmaminaats u defined by the Bay Area Air Quality Management BOILER.COMP(OVER 100.000 BTU) p�
/Y
district? ❑
trict7 r AID
Yes 13 Not NEW RCSIDEN'1'IAL MECII. SQ.Ff.
I have mad the hamNoua mamnals requimments under Chapmr 6.95 of the `,ill Nor
Califmtin Health h Safely Card,Sections 25505,25533 and 25534. 1undersand Nat �jr Ib r
if the building does not currently have a tenant,that it is my responsibility r nobly the
aceupam of the milli a ucal.which must be met pour to issuance of x Certificem of /s ry,1
Occupancy. V'r f UF- cu, I O
Owner or authonmJ agent Date 0 Al: ISSUEDITY
OFFICE