26649 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ' "� A• PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 26649
BUILDING DIVISION BUILDING PROs IDENTIFICATION
BUILDING ADDRES.' SANITARY NO. APPLICATIONSUBMTITALDATE.
I J
NIT# 1,01'p
OWNERSN PHON : ONTR O AME: LI /
NIC CONTROL#
*�RCHI /ENGI LIC NO: ADD:
S J ql �} ❑
CONTACT: PHONE: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE F-1 El I] El
LICENSED CONTRACTOR S DECLARATION APPLIANCES-RESIDENTIAL f08 DESCRIPTION
nyz Iherebyaffirm that l am licensed underprovisions ofOapmr9(commeneingwith !{�
woo Section]000)of Division 3 of th stress and Profits s Q ,and my license is in PANELS f�/Y"
yW��—,, full Torre anS�� �/ l�
<Z' License ass Lm.p _ UPTO2WAMPS
ti<y Date Contractor 201-IOW AMPS
ZOr"is- ARCHITECTS DECLARATION OVER 1000 AMPS SQ.IT.FLOOR AREA $/SQ.FT.
O o—_ I understand my plural shall be used as public records.
F r"F W SIGNS ELECTRIC
6� Licensed Professional
�yKA C
6 OWNER-BUILDER DECLARATION SPECIUFGMISC.
te. 1 hereby affirm that 1 am exempt from the Contractors License Law for the
m 3 a rn following reason.(Section 7031.5.Business and Professions Code:Any city or countyP.METER OR POLE INS'.
which inquires a permit to construct,skier,improve,demolish,or repair any structure
of
gs�}� prior to its issuance,also requires the applicant for such permi0o file.signed stammenl POWER DEVICES
K Q O
but he is licensed pursuant to the provisions of the Contractors License Law(Chapter
o�1 9(commencing with Section 7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
p s_^y or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FlXTURES
F-Z>' Section 9031.5 by any applicant for ape.it subjects the applicant to a civil penalty of
not more than five hundred dollars($500). NEW RESIDENTIAL FLECTR 5
z ❑ I.asownerofthepmpcny.ormyemployeeswithwa mmt irsolecompensalion, Q'FT. STORIES TYPE CONSTRUCTION
a3:L will dothework.rod the sncmrt is not intcridedaroffemd forsale(Sce.9044,Business
and Professions Cade:The Contractors License law does not apply to an owner of
property whobuiIdsorimproves thereon,and whodrys such workleare elfor through his
own employees,provided thatsuchimprovemems are not intendedaroffered for sub..If, OCG GROUP RFS.UNITS
however,the building or improvement is sold within one yearofcompletion,the owner- TOTAL
builder will have the Imrden of proving that he did not build or improve for purpose of
sic.).
❑ 1,asownerofthe propcny,annexcladvely contracting with licensed contractors to QTY. PLUMBING PERMIT FEE FLOODZONE APE
construct the project(Sm.9014,Business and Professions Code:)The Conrracror's
License Lawdoesnotapplym anoenerofpropcnywho builds orimproves thereon,and PERMIT ISSUANCE
who contracts forsuch projects with accouterments)licensed pursuant to the Cuntrarim's
License Law. ALTER-DRAIN&VENT-WATER(EAJ FEE SUMMARY
❑ I am exempt under Sec. ,B ffi P C for this mason BACK PLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Date RECEIPT'p
DRAINS-FLOOR.ROOF,AREA,COND.
WORKMAN COMPENSA'1'IONUECLARATION SCHOOLTA% YN
❑ Ihereby affirm
oustai Insurance,
M.ceateof cap,thtoself-insure,oracenif¢am of FlXTURES-PER TRAP REC8IPI'p
o keri Cnmpensmion Insurance oracertified copy the (Sec.3gW,lab CJ which PARK FIE Y N
covers all en+otraee'aypd-ouhis mwC GAS-FA.SYSTEMA INC.4OUTLEfS - RECEIPT N
Policy. BUILDING DIVISION IVES
Company �J - GAS-PA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is h reb famished.
�tbnified copy s fled wi inspection division, GREASIVINDUSTRL WASTE INTERCEPTOR GRADING ITEI1
C 'TIFICATEOFEXEMPDON MOM W KERS' GREASE TRAP SOILS FEE �
COMPENSATION INSURANCE
(Thismcti nnedlnotberompletedifthepermitisforoneh pdreddellars($IW) SEWER SANITARY-STORM EA.200FT. ENERGY ITP.
or leas.)
Icenify at in the perfomunceof Ne work far which flus it is issued.l shall WATER HEATER W/VIIIELECIR
not employ y person in any marmer so as to become sub a m rhe Workaf PAID
Compensati lawsof Califomia atg WATER SYSTEM/IREATING Date Recei,#
Q z Applicant
z0 NOTICE APP. T: frer 'enifica¢of criterion,you should NEW RESIDENTIAL PLMB. SQ.FT. TOI'A1.;
hwnme s jet r erten piuds ons of the bar Code,You must
�i :> foriv, o sue provisionsonhispermitashaRbe toed revoked. BUILDING PEE
LU r m SEISMIC EEE,
6. Q CONS RUCTION LENWjJG ENC
I efor affirm that a iso osf�su[ios(le�dia enc for N<p<rfwmantt of
,z !WW// ',Flee,//{{ TOTAL: a F.LECfItIC Ili[
U O thew #for which Nis his (S� v .)
Lend 's Name
U-' F Lend is Address QTY. MECHANICAL PIiRMIT FEE PLUMBING Fre
U ccnify that I have read this appli tion a . m thattthe above infnrmmion is
�"' W car r.l agree to comply with all city an�.a myonlumovessnd state laws mlatingio PERMIT ISSUANCE
MHCIIANICAI.ITE;
F' build gconstractlonandhemb Sze repracntatives of Nisciry in enter upon the CONSIHUC'UONTAX
U z above entered Paint uspecriom purposes ALT17R OR ADD TO MECH.
( a ve,indemnify and keep,harmless the City of Cupenino against -
liabilitiesjudgmentscrucsaodeapcnsex which in,inany way accme against said City AIR HANDLING UNIT(TO 10,01al)CFM)
in consequence of the growing of this permit.
AIR HANDLING UNIT(OVER IU.0(0 CFM)
EXHAUST HOOD(W/DUCI)
Signature of AppllcmUCanvaemr D.lc ,. PAID
IIAYARDOUS MATERIALS DISCLOSURE. HEA UNIT(TO 10I TU) Date Receipt
Will the applicant or future building occupant mom or handle hazardous material HEATING UNIT( RIW.IKK)BTU)
a.defined by the Cvpvmrn.Mum, al Cade,Chapter 9.12,and the Health and Safety TOTAL:
Code.Section 25532(a)'1 r / VENTILATI FAN(SINGLE RESID)
❑Yes -, �'f'
Will the appliv torfcumbei goccupant use equipment cadevices which emit BOILER-COMP(3HPOR IW,(1008II)) gl l�yUAN[1Ii DATE
a haamdous air cmounirmnI apo red by the Bay Area Air Quality Management BOILER-COMP(OVER 100,(MIf1BTU) Y' ev 1 LY
D,am,R11 '1995
❑Yes NEW RESIDENTIAL.MF,CTI. SQ,FT.P_ APR i+ IJJV
I have read the haadous materials requirements under Chapter 6.95 of the /s
California Health&Safety Code.sections 25505.25533 and 25534. 1 understand that `ill Ur UUrLrtl INU
if the building a rmuly have Immo r,rbt it is my responsibility,.purify rhe
tic to yui�nC_ - ton bc.mer prior ro i.�✓//-7,6edifivid Ad
/aupL (. "C
Owne auahMimd:gcm Dam l'OTAh: SUP Y: �d"_
OFFICE
•ADDITI0lTAL PERMIT FEES _
BUILDING PROJECT I DENTI FICATION wnLunnaN -
owN DES
ME FEE SUMMARY
PRONE
CONTRACTORS - BUILDING
NAE w,t m"oc &t4�� L-1i �� . .
"/ PLAN CHECK '
C CTORs - FEE. '
s01311EooREu
-' PHONE SEISMIC FEE
OTY. - ELECTRICPERMIT FEE
OUTLETS-SWITCHES-RECEP - ELECTRIC
LIGHTING FIXTURES PLUMBING
APPLIANCES-RESIDENTIAL
PANELS MECHANICAL
SIGNS
SIGNS TRANS. - TOTAL / •�
.SPECIAL CIRCUIT
TEMP.METER OR POLE INS. PEemrt vauonnoN
MOTORS SEE FEE SCH. "
O SER VICECHANGE - r
zZ1
F o TOTAL
CC T ` - ISSUANCE DATE
W _ OTY. PLUMBING PERMIT FEE BLDGELECT. PLG. MBCH.
.� 2 . ALTER-DRAIN&VENT-WATER IEA.1 El El El
U O BACK FLOW PROTECT.DEVICE
O•.w, DRAINS-F LOOP,ROOF,.AREA,COND. -
} a FIXTURES-PER TRAP
w
2 GAS-EA.SVSTEM-1JN C.4 OUTLETS
- (� GAS-EA.SYSTEM-OVER A IEA.)
INDUSTRIAL WASTE INTER.
LAWN SPRINKLERS-1 INC 5 V.B.
LAWN SPRINKLERS-OVER 5(EA.)
SEWER-SANITARY-STORM EA.200fd -
WATER,HEATER W/VENT
WATER SYSTEM j
*�WATER.TREATING EQUIP.
k/
QTY. MECHANICAL PERMIT FEE
ALTER OR ADD TO MECH.
- APPLIANCE -
AIR HANDLING UNIT(TO 10,000C.F.M)
AIR HANDLING UNIT(OVER 10J100C,F.M.)
EXHAUST HOOD(WITH DUCT) '
HEATING UNIT(TO 100,000 B.T.U.)
HEATING UNIT(OVER 100,000 B.T.U.)
VENTILATION FAN(SINGLE) :
BOILER-COAM(3H.P.or100,000B.T.U.)
ROILERCOMP 10..E lOo 000 BTU)SEE EEE SCR.
.TOTAL -.
b