26065 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO •• PEamrr No. 26065
PLUMBING
HUILUAPPLICATION/PERMIT ING DIVISION BUILDING PROJECT IDEN'1'IFICATIDN
BUILDING ADDRESS: SANITARY NO, APPOCATIONSUBMITTALDATE
22 l4Cp �f4/� C74 C� f♦«`Fina, C/G(, LOT# 02 0If
OWN ? MF,: PHONE: CONTRACTOR'S NAME: LIC NO: N/C CONTROI.0
s e
ARC ITECf/FNGINECR: LIC NO: ADDRESS: ❑
dE i /�e�so 2D2 3
CONTACT: PHONE: BUILDING PERMIT INFO
AA QTY E r* ELECTRIC PERMIT FEE
GailLes/'e C/'w5) .741—I rfoo PERMIT ISSUANCE B ELEC PLUMB MF.CH
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL 1:1 El PLUMB
JOBD RIPDON
OKZ IM1ereby of Division
amlicensedunss old irofesioCTepter9(commencing with
gi1O0 Section7000)
andefecivisionJof Ne Business old Profusions Cade,and my license is in ppNPrS _
o:� fan a,rce and effect.
FZ License Class Lica UP TO2W AMPS
E, Dam Connector 201-1000 AMPS S .FLOOR AREA 8/SQ.IT.
Zc)r Za ARCHITECT' 0 S DECLARATION OVER 100AMPS Q.Irl'
O Z�C 1 understand my plans shell m used m public records.
Licensed Professional SIGNS ELECTRICAL I :n I(— ED I N
rryLL OWNER-Bempt frmEC Contractor's
ontra ON SPECW.CBtCUIT/MISC. 1' s 747 `�T tl�
W O a F 1 hereby affirm,. Sethat 1.m exempt from the Cocoons Co License Lew for the 1 / r>•.,a
1:13OrQn which following reaeapermtian7031.5.Businae and professions disians Cade:epairm or county TEMP.METER OR POLE INST. rY�j1
F]y.] which requites n permit to construct,stem,improve,demolish,or repair any ewenue „s.
f >n prhomita xx...ra,alsorcquims1h..,Iicam Nrauch perminOfleadgnedememem POWER DEVICES
Wp O that he is licensed pueuan to the provisions of the Contractor's License Law Chapter
p. o 9(canunencing with genion 700o)of Division3of the Businessand Professions CON) SWIMMING POOL ELECTRIC ATE LUATI
yYj❑y or thathe is exempt Ncrefrom and Nebair for the dleged exemption Any,Wman Of OUTLETS-SWITCHES FIXTURES
� u
Z¢ Section by any upPlicant for a Permit subjects the mplicano a civil penury of - -
f G not more than five hundred dollars(8500).
K p ❑ Lasowneraf Neproperty,ormyemploymswiNwagesus Neirsolewmpensadon, NEW RESIDENTULELECrR _SQ.FT. STORIES TYPECONSTRUCTION
waldo Nework.and Oteslmclueisnmintenaedwaffemdfora ctSec.7W,Buaineas
and Professions Cade:The Contractors License Law does not apply to an owner of
Property whobuildsorimproves Nenceraad whodoessuchwork himeadforthrough his OCC GROUP RES.UNITS
n employecs,pmvidrdthat such impevementsmormintendedorofered foredo.If,
however,the buildingorimprovernent is sold withinoneyear ofeompledon,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,asownerofthopmpny.amexclaivelycmantxgwiNlicen dwa ctorsro QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
consumer the project(Sec.7046,Business and pmessions Code:)The Contractor's PERMIT ISSUANCE
License Law does not apply to an owner of propeny who bui Id s m improes vthereon,and
who contorts for such projects with awntractor(s)licensed patsumn in the Convector's T
W
GRAIN EA
License law. ( ) FEESUMMARY
❑ 1 am exempt under Seo. ,B&PC for this rea on BACK FLOW PROTECT.DEVICE OUI SIDE FFES
SANITARY Y N
Owner Date RECEIPT a
AREA
DRAINS-FLOOR.ROOF, .COND.
WORKMAN COMPENSATIONDECLARATION SCHOOL TAX Y N
❑ Thereby affirm Nntlh.ve acenifcum of cnnsem roselhinsurt.airs<enifcme of FIXTURES-PER TRAP RECEIPTa
Wmlers'Cour,mad s.hvaranesm.,rtiaedmpy thbrcof(See.3800,Lab C.)which PARK FEE Y N
coven all employees under this permit. GAS-BA.SYSTEM-1 INCA OUTLETS - RECEIPTa
Policy p BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(LA) PLANCHECK FEE
❑ Certified copy is hereby furnished.
❑ Certified copy,is fled with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section mad not be completed ifthe Permit is farms,hundrtddollon(SIW) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or Ins.)
I cenify that in the perfomunce of the work for which this permit is issued,Ishdl WATER HEATER W/VENT/F:LECTR
nm employ any person in any manner so a in become subject to the Workers' PAID
Cmmpe Ionlawsof Qlifomh. Dam WATER SYSTEM/IREATING Date Receipt#
O z Applicant
z 2 NOTICE TO APPLICANT:If,after making this Catificam of Exemption.you should NEW RESIDENTIAL PWB. SQ,FT. TOTAL:
F-1 In become subject to the Worker's Compensation provisions of the labor Code,you most
C� forthwith comply with such premieres or this parent shill b,deemed revoked. BUILDING FEE cc a-_
0. [� CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz 1 hereby affirm that them is a construction lending agency for the performance of TOTAL: ELECTRIC PEE
O the work for which this permit is issued(Sec.300],Civ.CJ
0 U Lenders Name
Lender's Address QTY. o,` MECIIANICAL PERMIT FEE PLUMBING FEE
V I certify that 1 have mad this application and state that the above information is MECHANICAL FEE
Da comber. I agree to comply with all city and county ordinances and sum laws relating to PERMIT ISSUANCE
rA building communities,and h<rcbyauNodse ecpresmtativanofdon.ity menterupon the CONSTRUCTION TAX
L) z
move-mentioned property far inspection purposes. ALTER OR ADD TO MECIL
(We)agree to save,indemnify and keep hermlers the Ciry.of Cupertino against
linbilities,judgments and expenseswNchmayina;�y c cog' id City AIR HANDLING UNIT(TO 10,000 CFM)
oa, i c tin this permit. //
NI. AIR HANDLING UNIT(OVER 10,000 CFM)
ignaemoI A mem/Caeecar Lpeote EXHAUST HGOD(W/DUC) PAID
HAZARDOUS Ming escape DISCLOSURE
HEATING UNIT(TO 100.530)BTU) Data Receipt is
Will the applicant orfurorebuildingm,Chaperreor bohandle Healtha material HEATING UNIT(OVER 100.000 BTU) T
a aefned by the Cupertino Municipal Code,Chapter 9.12,end the Health and Safety
sa
Cade,Section 25532(.)? VENTILATION PAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
1. Will Neapplicamwfuturc buildingmcupanmxequipmemwdeviaswhichemit BOILER-COMP(3HP OR IW,OW BTU)
haerch m air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER Hat"RTU)
imict? ❑ 11PAID
Yes No NEW RESIDENTIAL MECH. SQ.Ff.
I have mud the hanarlous materials rmuimmees under Chapter 6.95 of the
California Health&Safety Cade,Sections 25505,25533 and 25834. 1 understand that MAR - 31994
if the building dues not currently have a tenant,that it is my responsibility to notify the
occupant of the req dremenu which must he met prim to issuance of a Certificate of
Occupancy. OR Uh uurI' .
Owner or authorized agent Dom TOTAL: ISSUED BY:
OFFICE