26613 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOli tjILI)INU.P.I.RCTRICAI. PF.RMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
OitaI,DING DIVISION _ BUILDING PROJECT [DENT IFICAT]ON 26613
BUILDING ADDRESS: /� sG/ SANITARY NO. APPLICA'I'[ON SUBMI I'1'AL DATI3
!2 SUWK" R NIT# I.OTN
A OWry/"YSN A�. 0 /� / PHnNE: _/ ACTORS ME: LIC
C`O: �l
M !/fl CONTROLg
ACHITI: HNGINEERE: ,i,,,, D LICN DDRES • w ❑ 445�21
CONTACT: Y PHONE// QTY. ELECTRIC PERMIT J`�_\.W_• FEE BUILDING PERMIT'INFO
$ ` -P72 PERMIT ISSUANCE BLDG ELIMT X. PLIJMg MI:CII
LICENSED CONTRACTOR'S DEC TION gppLIANCES RESIDENTIAL JOB GSCRIPrI—ION
POO Thereby.(`rtmhml..like ed rials rit isiois ewinas Code (commencing itcese with /
+(100 fall
9l%q)of Di "on3of the Businase and Professions Cnde,end my license is in ppNElS
WeI-- full force and
QOgW I,iccnu Chrssc t. Lick ' 1��`M1SS J ` UP TO 200 AMPS 74
rF.,F�jQ1 Dale GM'SD 201 OVER
BEE AMPS t VYr S -
'LOy ARCHITECPS DECLARATION OVER It00 AMPS �$ OOR AREA S/SQ.FT.
O Z-p I understand my plans shell he used as Public records. tN/
F..N. J SIGNS ELECTRICAL �) 72-
yS¢ hiccnud l'mfesnionel OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MI$G. /
M
KK (( 71/7- �,'I
i45O0.F 1 hereby.flirts that 1 am exempt from the Contractors License Law for the � \1 7 - I e
ttl3 t'•m¢ followin"anin.(Section]031.5.Business and Professions Code:Any cit,mmunry TEMP.METER OR POLE INST. I CC
which reyuires a permit m camilo a,alter,improve,demolish,or repair any suucam, I
Q'i prions im ammicc,also requira,lmapplam,f�r such Permit file.signamitemcnt POWER DEVICES (I�
yy�O that he is licensed paramount o theprovisions ofthe Contractor's License Law(Chapter V
R•xe� 9(commencing with Seninn9Ufg0 ofDivision3oftM1e Basions and Professions Code) SWIMMING POOL ELECTRIC LUATION
W-m or that he is exempt dicocrom and the Fasts for alleged exemption.Any violation of UTLETS-SWITCHES-FIXTURES 1
ty> Saction903L5 by any applicant into pear:il,ubjmu,l,c applicannoa<ivil penalty of
G
ran name than live hundred dollars($500).
� m n❑ 1,asownernfihepropeny,ormyemployeeswlthwagesastheirsolecompensetion, NEW RESIDENTIAL ELECIR _SQ.FT. S'ORIBS 'TYPE CONSTRUCTION
y3- will do he wark,.nd the structure is not imenacdnraffimad far sale(Sea 7044.Business
and Professions Code:'I'he Gmtramor's License Law does not apply to an owner of
property who builds or improves macron,and who doer such work himadfor thmugh his
waemployees,providW that such improvermasur,not intendedoroffemd fnrsala.If. OCCLGROUP RES,UNITS
however.mebuildingor improvement is sold within one year ofcomplation,the owner- ) ��
builder will have the burden of proving that he did not build or improve for purpose of
❑ L,nownemRhe pmpcny,am exclusivelycontmaingwithlisensed wnuactarnm QTY. PLUMBING PIeRMIT FEE. ROOD zoNli qPN
onswet the project(Sec.9094,Business rand Professions Code:)The Conuacrs
License Low docs not 011,111.at ownarrfpmpeny who builds or impmvaetha,=ms.A TP17RMI'IAISUANCE
who contracts forsuch projects with a convactor(s)licenecd pursuant to the Contractor's11
License l.aw. ALTER-DRAIN&VP.NT-WATGR(FA) O• FEE SUMMARY
❑ ]am exempt under Sm. ,B&P C for this reason BACK FLOW PROTECT.DEVICE UT IDL' '1;1:5
SANITARY YN
Owner Data R17CETRI'p
GRAINS-FLOOR,ROOF,AREA,CONED.
WORKMANCOMPI?cuteof COMPENSATION DECLARATION SCHOOL TAX - Y N
❑ the Compe3rm en Insurance
vex unit cialeofcap,therciff(iosure,or Lab C.)wtach FIXTURES-PE.RTRAP RI?CEIPTp
Warkeri Compensation Insurance orucenifieJ copy thercof(Sec.3500,Loh CJ which PARK IEE VN
covers all employee's under this permit GAS-EA.SYSTEM.I INC.4OUTLETS
iCF.I k
Pin icy ft JOA 1 6 � BUILDIN N FGES
Company GAS-EA.SYSTHM.OVER 4(EA) PIANCHECK FElt
❑ Cerrifim copy n hereby fumishal.
❑ Ceniped copy is filed with theciry ins on division. OREASInND115•TRL WAsTR INTI?1tCEF1'OR GRADING F?I?
IsEW
CERTIPICATEOF ;MPI'IONFROM WORKER.' GREASETRAP SOILS PT'. ll
CO SATION INSURANCE
(Thisseclimmatedn
completed if Ne permis is(crone handle ollum(fl W) SEWEEA.20UPI. ENERGY
or less.)
I unify tin Be perfornanca of rhe work far hich Nis permit isu ved,Ishall WATER HEATER WryIiN'1'BiLECI'R
not employ a y person in any mwme?. as t subject m t Woheus' PAID
Compcnaetion cans of ilomia. Dae WATER SYS'113M/fREATING Dale ceiptg
p z Applicant
z 0 NOTICIi TO At LI A fte ng this CeriBcate n.yo honld NEW RF:SIDENTIAI.I'LMN. SQ.FT. 1TA1:
F (/] become subject to e lmpevuion syft a bo ode,yo .11
a ; forthwith comply 'th sac Psvi' this�I is all he damcd._,ked. BUILDING PER
w A
LTa Q ON UCTIO rLENDING AGENCY SIiISMIC FEB
I hcrcby aflirmt ahem is ecnnswction landingagenc thcperfmnmcaof 'I 1 ?LLCI'RIC FI?E
U 0 the wmkforwhichthis rmitiaiasuad(sec.309],0s. 4
Lender.,Name
� U Lenders Address Q'PY. MECHANICAL PERMIT FEE PLUMBING FEE
1 ecrify that 1 huv rad this applic nand acme that the above information is
correct.l agree to comfit with all ci nd county ordinances and sunt laws relating to PERMIT ISSUANCE. MECHANICAL
f-' buildie,carl OuNon.an arc thodurepmsenwtivesofthiscitywemerupon the
V 7 .hove-meolimedpropeny rmspectimpurposes. ALTER OR ADD TO MECH. CONS9RUC1'ION TAX
kggrce m save,indemnify and keep harmless the City of Cupertino go.it"
Itities.judgmrnts,costs laid expenses which may in any way accrue.gains said Ciry NR HANDLING UNIT(T010.000 CFM)
nxeyue anfmcg tial nfflix,rmit.
�a AIR HANDLING UNIT(OVER Io,100 CPM)
O_
S' amre (_omr.cm, Dem J EXHAUSTHOOD(W/DUCI'I
PAID
ITA%ARDOUS MATERIALS DISCLOSURE. HEATING UNIT(TO 100.010 BTU) Ira Data Receiptp
Will the applicant or future building mcupam store or handle hazardous material HEATING UNIT(OVER IW,(00 BTU)
m defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and S.faty
Cade,Section 25532(.)'1 VENTILA'PION PAN(SINCLC RIiSID)
❑Yes ❑No itz
W III the applicam or fumrc building cecupam use equipmem or devices which emit
BOILER-CAMP(31IP OR 1(0,00(1 pTU) ISSUANCE DATE
momus air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 101,000 BTU)
canc'I
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.IT'.
W A
1 have read the Incursions matem
rials rer,moents under Chapter 6.95 of the Y
California Health&Safety Coda Sections 25505,25533 and 25534.1 understand that as��
i I he End ding dtma not caoanly have a tenant,that it is my responsibility to ramify the 1T
oempunt of the reyuicarrams which most Ire met prior to issuance of a Certificate of
ea.papey. C(7}
Ownernmanxizelti,in Data
ISSUI?DBY:'�al•�+
OFFICE