26223 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOA PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL C O
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION O J
BUILDING ADDRESS: '- SANITARY NO. �M�FLITIONSUBMFFEALDATL
2zo �r
( UNIT# LOT
OWNERS NAME: ,^ PHONE: ACTOR'S NAME: —.LLC NO:
11/n �SrY.I �C £ y NEC CONTROL#
C
IRCHITE /ENGINEER: YJ LIC NO. ADDR%SSS:/Z � ' �� ❑
CONTACT: PHONE: QTLY. G ELECTRIC PERMIT FEE BUILDING PERMIT INFO
G E PLUMB MECH
PERMIT ISSUANCE El
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL JDBDESCRIPTION
mxz I hereby affirm that l um licensed underprovisionsofChapter9(commencing with
FOO Section 9000)0[Division 3 ofthc Bu,insssand ProfessiCode,and my license is in PANELS
CWT-+ full
nsforce
andeffem.
Xyl License
Lic.# UP T0200 AMPS
m 60. Dme Comment 201-1000 AMPS
ZO7y OVER 1000AMP5 Sp FTIrlO(pr7ytEA $/SQ.FT.
NZ ARCHITFCPS DECLARATION yP PP66��.... 1III1I5SJJt�
O Z o,— I undmslood my plan,shall be used as public nowt
r'1,w SIGNS ELECTRICAL
G��,„2j Licensed Professional
CaC6 OWNER-BUILDER form
m the Contractor's
SPECIAL CIRCUIT/MISC. I ��
xOyF 1 hereby n(Se That I am exempt from the Gonion Co License Law for the
W 3 W y following reueon.(Section]031.5,Business and Professions Code:Any city mcounty TEMP.METER OR POLE INST. _
E' which requires n permit to const,um,alreq improve,demolish,or repair any stmc[ure �.
S�}� prior to is issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES k
that he is licensed pursuant to the provisions of the Contractors License Law(Chapter
a. �C 9(commencing with Sort.7000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VA N
W or he is assault therefrom and the basis for the aIle Wexem In.Any f
p4 f,cog ptnaiomo OUTLETS-SWITCHES-FIXTURES
HZa Sectionmethan56y any ve hundred
lours 06500mit subjects the applicant aelvil penalty of Y
Cxx not ml,asown rafthe roe rtyllars ympl Q. STORIES TYPECONSTRUCTION
IW^m ❑ I,axowneroftheproperty,ormyemployees with wagesastheirsolecompensation, NEW RESIDENTIAL ELECTR S FT. ,
will Bothe work,amd[hesomeone is not intended or offered far mile(See 70,14,Business
and Professions Code:The Contractor's Licence Law does not apply to an owner of
property who builds or improves thereon,and who does such work himsel for through his
employees.providN[hat suchimprovementsare not in¢ndedoroffcrcdfnrsale.If, OCC.GROUP RES.UNITS
however,the building or improvement is sold within one year ofcompletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
ante')' QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ ].construas the project
rofit(See. 0y 1,Business
andely Professions
with licensed wnGtractoto
License Iwo does
a.,(See.9044,Rosiness and yw1wi ild Crede:)The Contractor's and
LicenserLaw doee such
apply mmith acofminants)whobed pursrimproves thereon,and PERMIT ISSUANCE
lwho amemeLaw.for such projects with acontmctoK,)lieemed pursuant Contractor's ALTER-DRAIN&VENT-WATER EA
l.can,a Law. ( ) FEE SUMMARY
❑ OUTSIDE FEES
I am exempt under Sec. ,B&P C for this reason BACK FLOW PRO'T'ECT.DEVICE
SANITARY Y N
Owner Dale DRAINS-FLOORROOFAREA,COND. RECEIPT#
, ,
WORKMAN COMPENSATION DECLARATION - . SCHOOLTAX Y N
❑ Ihereby affirm[hat l have amnificalsornonsemm self-insure,oracesificateof FIXTURES-PERTRAP RECEIPT#
WorkersCompensatiminsumeecracesifiedcopythereof(See.3804Lab C.)whlch PARK FEE Y N
covers all employee's under this permit - GAS-G.SYSTEM-I INC.4 OUTLETS RECEIPT#
Polh:y M BUILDING DIVISION PEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ C.00 d copy is hereby famished.
tified copy is Bled withtwe city inspection division. GRE,SE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one hundred doll.5100) SEWER-SANITARY-STORMEA.200FT. ENERGY FEE
orless.)
I certify that inthe performance ofine work for which this permit is issued,l shall WATER HEATER WIVENT/HLECTR
not employ any person in any manner so a,in become subject to the Workers' PAID
Compensation Lawsof Califomia. Date WATER SYSI'ENUTREATING Uate Rceipl#
C) Z Applicant
zO NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FI'.
become subject to the Worker's Compensation previsions ofthe labor Code,you mus[
� , foMwith comply with such provisions or this cenrdt shell be deemed revoked. BUILDING FE
A CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1 hereby affirm that them is a construction lending agency for the performance of TA ELE 1
U O the work for which this permit is issued(Sec 3097,Civ.CJ
lenders Name
u" F Lender,Address QTY. MECHANICAL PERMIT FEE PL G
U 16
1 cosily that I have read this application and stale that the above information is .,DAN HANI FEE
s�" 4T1 oortect. lagrce mcomply with all city and county ordinances and state lawarelatingm PERMIT ISSUANCE
huilding enncwedon,w hereby eothorizerepresmtatives of this cirymen[er upon the
U z CONSTRUCTIONTA
above-mentioneipm sy for inspection purposes ALTERORADDTOMECH.
(We)agmc save,indemnify and keep site City of Cupertino against
Iiabildien,jud mts,costs ands eswhic ay in. try worm against said City AIR HANDLING UNIT(010,000 CFM)
corset¢ cofthe grami of its,pe
r( 30 AIR HANDLING UNIT(OVER I0.000 CFM)
Signemre of Appli nnUContractor Date EXHAUST I IOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000 BTU) - Date Receipt#
Will the the Capsimuant furore building xoupmuer 9.o,hanand the
Heamors lth and
HEATI NO UNIT(OVER 100.008 BTU) T
al
as dufinad by the Cupertino Municipal Code,Chapter 9.12,end the HeaIM and Safety
Code,Section 25532(,)2
L3 Yes ❑No VENTILATION PAN(SINGLE RES1D)
ISSU NC ATE
Will Woapplicant orfutumbuilding occupant use equipmentordevlceawliichemii BOILER-COMP(3HPORI00.000BTU) -
bromine,air contaminants as defined by the Bey Area Air Quality Management BOILER-COMP(OVER IOU(SIDBTU)
District? �y A '
❑Ycs ❑No NEW RESIDENTIAL MECO—SQ,M.
1 have read the hazardous materials requirements under Chapter 6.95 of the - �py�(
Califomia Health&Safety Code,Sections 25505,25533 and un
25534. 1 dcrstandthat MAR 301 O/f
if the building does not currently have a tenant,that it is my responsibility to notify the
eccupam of the regolremem.,which must be mel prior m issuance of a Confirms of CIry
Occupancy. 1
VIP?
IAV
Owner or uumhorized,gem Date L: ISSUEDBY
OFFICE