26966 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO - I IIXJ ELECT HICA- PHEMEPNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 26966
� 6 9 6.6
ItU11,DING DIVISION BUILDING PROJECT IDEN'TIFICA'TION G
HUILDINC ADDRESS: - SANITARY NO, APPLICATION SUBMITTAL DAPI
2 39 57E1�Eivs ,�.Blip,,Cu2T�/1bB�,'Csy c1 —'1-- LP
OWN [� Jx/.� ONTR CIOH'SN F LIC NO:
N/C CONTROL
RCIIITECf/fiNGINIiF:R: LIC NO'. ADD :SS: - ❑
'ONTACT: PHONE:
QTY. ELECTRIC PGRMII' PI?E IJUILDINC PERMIT INFO
L ELF❑.CT PLUMB ME❑Ctl
PERMIT ISSUANCE;
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL.
I hatch IfimUhatl em licensed under rovisinm of@u d 9 n gwi JOB DESCRIPTION
P100 Section 7M)of Division]ofthe Business and Professions Code,and my license is in PANELS ���I 7...y�� ,D 5
Pocnse Cand cffccL UPT02MAMPS `�` I 1 ` Y ,
V
cdr.,Z$W License Cluaa Li,N
o, Date Contractcr201-P"AMPS
7 FO 5,,z' ARCHITECTS DECLARATION OVER I(Xp AMPS SQ.F)'.FLOOR AREA $/SQ.ITT.
O Z.�M IanderswmPmy plans shall heated aspublic records.
F y f oW SIGNS ELECTRICAL
2 j Licensed Professional
ww< OWNER-BUIL.DER DECLARATION SPECIAL CIRCUITIMISC.
gOyU I hereby affirm that 1 am exempt from the Commons's License Law for the
tz�30.y fol lowing mason.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
�TI which requires a permit to construct,alter,improve,demolish,or repair any structure
IVVls}� prior to its issuance,also mrmiss the applicant for such Permit o rile a signed statement POWER DEVICES
<0 fin he is licensed pursaanno the prionsions ohne Comment's License Low(Chapter
o• o� 9(mmmencing with Section 7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
or that he is encrop' herefmmand the hasis Far me Aleged exemption.Any emsionaf OUTLETS-SWITCHES-FXI'URES
p�Q $enion]03 LS by any appticam fornpermit subjectsdhe epplicanno acivil penalty of
mnm morethan l lvebuid dollars($500). NEW RESIDENTIAL.PLP,CTR -SQ.FT.
❑ I,usnwnerofNepmperty,armyemployarwiNwagesuxtheirsblecompensatio STORIES TYPECONSTRUCTION
6 will do the work,nnd the structure is not mutated proffered for snle(Sec.]IW4.Basin s
and Professions Cade:The Cnmrectur's License Law does not apply to enw of
property whoballdsbrimproveslhereon,and whodoes such work himselform_ gh hie
own employees,provided that such improvementaaream intended muffle. beside.If, OCC.GROUP RES.UNITS
however,the builJingorimprovement is sold within one year of temple' t,dh a t '10'1'AL:
builder will have the harden of pmving that he did not build Ur imp a for pputw of
❑ I,vs bwnerofthe PropenY•umexdusivelYcontractingwiN ensure t o Ql' I.UMBING PERMITI'EE FLOOD ZONE APN
an,ormu t]to projoct(Sec.]044,Bnsinexe and Professions a a0 The t coca's
License Lawdsxsnrn epplyman ownerofpropeny whab' impro , .,and )ERM II' SUANCh
whnamxans fnrsucM1 pmjecds with aconOt¢mr(s)lic dpursuan monstrous q •R-DRAIN&VENT-WATER EA
License Law. I ) IEE SUMMARY
❑ I um estops under Sm. C for this res AC LOW
PROTECT.DEVICE OUTS,IDP S
Owner SANITARY Y N
DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT0
WORKMAN COMPENSATION DE RAT N SCHOOLTAX Y N
❑ I hereby affirm thatihaveaceni fare of consent Se 'nsur to certificate of RECEIPTN
FIXTURES-E'ER TRAP
Wvers al CmployeeS moor this permit.
fled copy thereof( .7gfp,labCJ whic PARK FIiE Y N
Covers all employee's undenhis permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RDIVISION
Company BUILDING DIVISION 3E5
.Company
[I Certified copy is hereby famished. GAS-EA.SYSTEM-OVER 4(PA) PLANCHUCK FEE
❑ Certified copy is filed with the city inspection division. OREASILINDUSTRI.WASTE ED ERCL'PI'OR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE'(RAI' SOILS THE
COMPINSURANCE
ThisseetionneW not hewn,leledifthepcanis is formichmalroldo1lms($100) SEWER.SANITARY-STORM EA.20017. FNERGY FEL?
or less.)
I cavity that in the perfonnanceofthe work for which this permit is issued,l shot[ WATER HEATER W/VIiNT/ELF.CR
not employ any person in any manner so as to become Subject to the Workout' PAID
z Compensation Eawsof Culifamis. Dare WATER SYSI'HMOKEATING Dave RcceiptN
Applicant
O NOT ICE TO APPLICANT:IL after making this Certificate of Exemption,you should NEW RESIDE Nf1AL PLMIL SQ,FT. TOTAL:
f~ (q become SLbjecuo the Worker's Compensation provisions of the labor Code,you must
a ; fanhwith comply widh such provisions or this pemtit steal[be deemed marked. BUILDING FIDE /R
a1] CONST RUCTION LENDING AGENCY SEISMIC FEES
Vz I hereby affirm that them is a construction tending agency for the performance of
Q the work for which Ods Permit is issued(Sec.NAO,Civ.C.) TOTAL: ELECTRIC FEE
Lender's Name
O U Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FIE
I certify that I have mad this application and situation the above information is
Wcorrect.l agree in comply with all city and county ordinances and state laws relating to PERMITISSUANCB MECHANICAL FEE
building construction,and hemby authorize representatives of this city to crime upon the CONSTRUCTION TAX
V Z ahe
ovmendoned Property for inspection purposes. ALT ER OR ADD I'O MFCH.
r (We)agree ro save,indemnify a d keep b rmiless the City of Cupertino eg.into
Iiabilidim,judgmems,cosband expo swhich any wayaccme against said City AIR HANDLING UNIT(TO 10,000 CFM)
in nsequen flhe mingof rmit.
AIR HANDLING UNIT(OVER IIh(gl0 CFM)
Si new o App suM mourt.r F Elmo EXHAUST HOOD(W/DUCO
PAID
HAZARDOUS MA ER ALS DISCLOSURE HEATING UNIT('E0 180,000 RTD) Dad, Receipt N
Will the applicant or future buildinb cupentstorem hounle hamrdous nwterial HIiATING UNIT(OVER IW,fgq PTU) T
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health,and Safety
Crede,Section Yea)9
11 's ❑No
VENTILATION FAN(SINGLE RESIDE
Yes
Willies applicant ter fmurc building acupent use equipment nrdevices which amid
BOII,ER-COMP(3HPOR IN."BTU) ISSUANCE DATE
zardom air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,(100 BTU) -
Distda9
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT, PA O 0
I have read the harardaus materials requirements under Chapter 6.95 of the ���
California Health k Safety Code,Sections 25505,25533m,,125:534. I undersmnd that
How building does not currently have a tenant,that it is my responsibility to notify the
occupant Yf the req timmems which must he at prior to issuance of u Cenifcam of ��'y f
Oce n 1
L�
Owner or authoriacd ngem 'Date TOTAL: ISSUED BY:
OFFICE