26771 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO A• PHRMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL, f�C
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION L v
771
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DAM
✓'���� 7V� UNIT# LOT# 1�i9�q
OWy° 'NA :: PHONE: C ACI'O 'g NAME: LIC NO: l TL#
EER: Co4/3/73 Z N/C CONRO
•ARCIIITfiCT/ENGWINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: QTY ELECTRIC PERMIT FEE y BUILDING PERMIT INFO
LO ELECT PLUMB MECH
PERMIT ISSUANCE 13 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
nedz
Thereby a0muthat l uicnednifsof Chapmmeiin
JOB DESCRIPTION00 Section]000Division 3ofthe Business and IPmessions Codle,andmylcamsenin PANELS:WUfull fore andeffect.
Fym License Class Lic.# UP TO 200 AMPS
F,Q=y Date Conitacem 201-I00)AMPS
70NG ARCHITECTS DECLARATION OVER IOW AMPS SQ.FT.FLOOR AREA S/SQ.FM
OZ-0 I rmdecaund my plans shall be used as public records.
P I.Q10o' SIGNS ELECTRICAL
Q,1zj Licensed Prolessional
�d.CG OWNER-BUILDER DECLARATION SPECIAL CIRCUIT I
jdOpW.F I hereby affirm thm I am exempt(mm the ContmanJs License law for Ne
El E,ia,rn fall owing.caaon.(Section]0315.Business and Professions Code:Any city re county TEMP.METER OR POLE MST,
F'4'0< which requires a peon[to construct,alcor,improve,demolish,or report any structure
nz >: prior to its issuance,also requires the applicant for such lmrmluo file a signed statement POWER DEVICES
Wu'p 0 that he is licensed Pursuant to the provisions of the Contractors License Law(Chapter
A.w.O! 9(commencing with Section 7")of Division 3 of the Business and Professions Code) SWIMMINGPOOLELECPRIC
W_y or that he is exempttherefrom and the basis for alleged exemption.An VALUATI!)_kCa
g p Any violation of Q
FZa Section7031.5bye hundred dofor a llars
subjects the epplicanuoacivil Penalty of OUTLET'S-SWITCHES-FlXTURES O— 1 ��
S 0 nm mom'Imn five hundml dollars(8500).
C ❑ l,asownerofthe n NEW RESIDENTIALELECB _SQ.FT.
grope y,ormyemordecswithwagesaseleir sole compensiioq STORIES TYPE CONSTRIICI'IOD
i _ will do thewons Code:
The Curcisna.,License Law
red does not
in an Business �r Jr,e:The Commcmrs License I�w does not apply m an owner of m r Ih"
Property who builds or improves thereen,and whodeas such work himselforthrough his .. I I f8, IN
hoemployme,provided thatsuchimprmemems atenot intended proffered forsale.If, v VD /t I —O RES.UNITS
wever.the buildingor improvement is sold whInnone yearofeampledon,dmown r- PA / L
builder will have the burden of prnving that he did not build or improve for purpose of
side.). QTY. PLUMBING PERMIT DA N
❑ I,00wnerof the pmpeny,amendusively convecting with licensrdconwmoreto I APN
ons'met the project(Sec.]044,Business and Professions Code:)The Co ments's r
Licenm LawdcesnotapplymanownerofproNnywhebuildsori.proves'herme,and PERMIT ISSUANCE -
who contracts for such projects with a commetor(s)licensed Persuanno the Conarst
Liccnee Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ l am exempt under Sec. B&P C for his reuwn BACK FLOW PROTECT.DEVICE OUTSIDE FEES
OwnerSANITARY YN
Date DRAINS-FLOOR,ROGF,AREA,COND. RECEIPT'#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Thereby affirm cen
that l have a ificamofecncem to sef-inxtrrc,or a cenifeatteof FlXTURES-PER TRAP REC[IPI'#
Worker,'Compensation Insurance or accnmec
ificd copy therf(S .38W,lsb C.)which PARKFEE Y N
cmeraoll employee's under this permit GAS-EA.SYSTEM-1 INC.4 OUTLITS RECEI #,
Policy#
BUILDING DIV] ION FEES
Company
IJ Certified copy is hereby famished. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Ceriticd copy ix filed with Ne city inspection divisina GREASEIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
INSURANCE
(Hdssemion need no'becomphood ifthe permit is parent,hundred dollars(SIM) SEWER-SANITARY-STORM EA.2WFT.
or less.) ENERGY FEE
I certify that in the performance of Ne weak for which Nis permit is issued,l shall WATER HEATER W/VENM(ELECTR
nut employ any person in any manner so..bmanc subject to the Workers PAID
z Compcnsminn Lawsof Colifomia. Doe WATER SYSTEWREATING le eceipt#
z2 NOI'ICI�'10 APPLICANT:IL after making this Cmdficam of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FP.
E-' y become subject to the Worker's Compensation provisions of Ne labor Code,you mustTOTAL:
forthwith comply with such provisions or this permit shall be deemed invoked. BUILDIN -E �.
put, Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that hem is a construction lending agency for the performance of
U O Ne work for which flus permit is Ended(Sm.3007,Ci,C.) TOTAL: ELECTRIC FEE
LT. P. Lcan, .Name
p V Len re's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
1 artily that 1 have mad this applicadon and stem that the above information is
Fcorset. lagmc.comply with all city and county ordinances and stem laws mladngm PERMIT ISSUANCE MECHANICAI,FTE
_ building conswmion,and hereby authonu representatives ofthis city to enter upon the
U Z above-menduned property for inspecion purposes. ALTERORADDTOMECH. CONSTRULTIONTAX
(We)agree In save,indemnify and keep harmless the City of Cupertino against
liabilities,judgmen's,costs and expense which may in any way accrue.gainsaid City AIR HANDLING UNIT G'0 IQOW CFM)
in go. e fthe granting of thi - rmir. AIR HANDLING UNIT(OVHR IO.OoO CFM)
fApplicanUC 7 Date EXHAUST 14WD(W/DUC)
PAID
HAZARDOUS MAMRIALS DISCLOSURE HEATING UNIT(TO IW,WO BTU) Dam Rove '#
Will the applicant or future building occupant store an handle hazardous mammal
as dribud by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU)
Code,Section 25532(u)?
❑Yes 0 N VENTILATION FAN(SINGLE RISTD)
Will the applicant orfumm buildin mace BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE^ # Ik/
gwapan quipmemmdcviccs which emir
hazardous air contaminants as defined by the Bay Area Air Quality Marwgemmn BOILER 100,(100 BTU) JUL n
DLstricll 9 1Q /J
❑Fes ❑No NGW RESIDENTIAL MF,CI I. SQ.IT. •`e�wY
I have read the hazardous materials requircmems under Chapter fi95 of the CITY ut- vUYtH/�N.
Cnlifomin Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that U
ifthebuildingdoesno'currentlyich m tenant thini'is toyssuancsiofa Innotify the
Occupant nl the requirements which muo be ten pont m issuance of a Certificate n!
fkcurymcy.
OwneroramhanzWagent Dam TOTAL: ISSUED BY: r
FA