26183 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO •.E1.r.CFRICAI- PERMITNO. r�
APPLICATION/PERMIT PLUMBING-MECHANICAL. L
BUILDING DIVISION BUILDING PROJECT IDENTIFICA'I]ON
6183
BUILDINGADDRSS Wo N LOT, SANITARY NO. APPLICATION SUBMITTAL DATE
OWN!!S Q PHONE: NTRACTOR:S ryAit; ;IC NO �
-'Z3si"�
J GG��.,((.nnWW.RR1111�KJJ sWi' N/C CONTROLp
4' LIC NO: #DDRESS:
1-7&0 El
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT'INFO
BLDG t'1.ECT P UMB MECH
PERMIT ISSUANCE / Y il -
LICENSED CONTRACTOR'SDECLARATION APPLIANCES-RESIDENTIAL t� jet\,
act I hereby affirm that l am licensed under provisionsofChapmr 9(commencing with 10B DESCRIPTION
FJO2 Section 7000)(if3 of the Business and Professions Code,and my license is in PANELS
K F. CC, ��
FZW I"icense In Lica UPT0200AMPS
,<o. Dam Convector 201-I"AMPS
Fy7 ARCHITIIC'S DEC RATION SQ.FT.FLUOR AREA S/SQ.FT.
Z O y— OVER IIXMI AMPS
OZ
1 understand my plans shall be used as public records. ���O
-y F; SIGNS ELE ICAL
aitb
Licensed Professional
�u�u11Q OWNER-BUILDER DECLARATION SPECIAL CI ISG.
x1 hereby urmm mat I on exempt from the Cnmmmor's License Low for tiro
W 3 LL v~i following mamn.(Section 7031.5,Business and Professions Code:Any city m county TEMP.METER INST.
F O¢ which requires a permit to construct,alter,improve,demolish,or repair any ehucture
edPrior to its issuance,also requites the applicant for such permit to file a signed statement POWER
C< mat he is licensed pursuant to the Provisions of the Contractors License law(Chapter
aaom0m 9(mmmencing with Section 7")of Division 3 of to,Business it Professions Code) SW G LECTRI VALUATIO�Liqal
09)
—y or that he is exempnhcmfromaml he basis home alleged enemy I Any violation of ^. w
�7Q Section]03 LS by any applicant Toru permit subjects the applicum to acivil penalty of L ITCHES- RES (— 1O /Il all
t more than unred live hddollars(5510).
f=C, noNEW RESID BLECI'R SQ,PT. STORE ti 'I'YPIi CONSTRUCTION
WC] I,asowncrofthe Mrop y.ormycmployceswirhwagetmtheirsolecompemabon,
d3— will dothe work,and the structumis not intended orofferel Bastille(See 7044.Business all
and Professinm Code:The Contractor's License law does not apply to an owner of
propenywhobulldamimpmves Merton.anlwhodoessuch work hinvelforthmugh his OCC.GROUP RES.UNITS
own employ es,provided that such impmvemetnsarenot itnendedoroffend forsNe.If.
however,the landragor improvement is sold within one year of mmplevon,the owner-
hadwill have the burden of proving that he did not build or improve for puryose of
PLUMG IT BINFEE D.pOD ZONE AVN
C] I,asownernfthepmpeny,amexclusivelycmuactingwiNtiansedcontrectorsto QTY.
construct the project(Sec.7014,Business and Professions Code:)The Contrxtoix
License law leasing apply manownerofpropertywho bull&amimpmvuthereon,and PERMIT ISSUANCE
whocontracn forsuch project-waltacontractor s)licensed pununnt m tM Contra<mrs
License Law. ALTF,R-DRAIN&VENT-WATER(Est) ` FEESUMMARY
❑ 1 am exempt under Sea .B&P C for this reason TSI DF.FEES
BACK FLOW PROTECT.DEVICE SANITARY V N
Owner Dat° DRAINS-FLOOR,ROOP.AREA,COND. W RECBIPI'p
WORKMAN COMPENSATION DECLARATION �-.ni SCHOOL TA% VN
C] Ihertby affirm Natlhaveecenificem ofconsent mselGinsum,areartificne of FlXTIIBM-PFR TRAP RECE M
Workers Comperuuinn lnsumncanrecerti0cd copy thcrtof(SaJ8M lab C.)whah PARK FEE Y N
urs all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS � 1 a
Policy a , Ill I DVI 1 FEES
Company GAS-EA.SYSTEM-OVER 4(CA) PLANCHECK PEAM I O
❑ Certified copy is hereby monistical.
❑ Certified copy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
CHtis section need atbe completed ifthe permit is forme hundred dollars($100) SEWER-SANITARY-STORM EA.20t ENERGY FEE
or lust
(certify Oast in the performance of the work for which this permit is issued, 11 TE IEE NT/B E �
not employ any person in any manner so as to become subject to the ns'I'; c PAID
Compensationl.awsof Califamia. Date V W F. YS L T Date Receipt
O z Applicant u .' ) - ID AL SQ.PT. TOTAL:
Z 0 NOTICE TO APPLICANT:If,after making this Ccnificele of Exemption.you vyoa
.I, become subject m the Workers Compensation provisions of the Labor Code,you must BUILDING FEE
> forthwith comply with such Provisions or this permit shall be deemed revoked. I]
0. [] C NSTRUCTIONLINDING AGENCY �— SEISMIC.FEE
z hereby affi h. Vert is a construction lending agency for the performance of
ELECTRIC FET:
U O the work for whin I mtit is issued(Sec.309],Civ.CJ
Lenders Name PLUMBING FEE
Lenders Address QTY. MECHANICAL PERMIT FEE
O U 1 certify that a read this application and state that the above information is MECHANICAL FEE
Corea. Iti m t ly withullcity and county ordinenasandstain laws relatingto PERMIT ISSUANCE
F^ U1 building a tact n nd hereby awhorize representatives of this city toenmr upnmhe CONSTRUCTION TAX
L) 'z ulawe-m o cd t ny to friction mummies. ALTER OR ADD TO MECH.
(W tg ttem ify and keep harmlcsr the City of Cupertino against
liabilities dn
( sande scawhichrrmyinanywayera
ccea 'claim City AIR HANDLING UNIT(TO 10,000 CFM) �rt
conuq rt I gr Lingo tM1s it.
AIR HANDLING UNIT(OVER 10,000 CFM)
Si, mrc of lieu Contractor Date EXHAUST HOOD(W/DUCr) O
PAID
HAZARDOUS MAT HR1ALS DISCLOSURE IIEA']ING UNIT(TO 100,004)BTU) Date Reccipta
Wi11Nea cant or future building occupat nom orhadkhazudous mmcrial HEATING UNIT(OVER 100,000 BTU) TO]'A '
as de cd by d penia Municipal Cade,Chapter 9.12,and the Health and Safety
Cale.S _55. (a)YVENTILATION FAN(SINGLE RESID)
13Yes C1 No ISSUANCE DATE
Willtheupprean orfuturebuildingoecupantmcequlpmenmrdeviceswhichemit BOILER-COMP QHP OR 100,000 BTU)
•bavardous it cone m mems as deincd by the Bay Arca Air Quality Manugemcnt BOILER-COMP(OVER 100,00)BTU) p 'i1JJ
s19
Diorinl p
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. 11� P+
I have read the havadous materials requirements under Chapter 6.95 of the K 23199 a
California Hculth&Safety Code.Sections 25505,25533 and 25534.I understand Nm r
if Ne building does at ateren0y h h anot(ant,thin it is my responsiof a Cc dri.n the �� V
wupnm of the rcyuiramcros which mon bn mm prior m isauunce of o CcniEcmc of ( r�
Occupancy. y b 1J
Ovocammahm rccl egcar Date ISSUED BY' r
OFFICE