26799 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO ituill or hLE - PERMIT NO.
BUILDING DIVISION
APPLICATION/PERMIT PLUMB ING-MECIIANICAI. 267
BUILDING PROJECT IDENTIFICATION G
BUILDING ADDRESS //�� SANITARY NO. APPLICATION SUBMI'TT'AL DAT
O /y/ O 'a APA
UNIT# LOT - ���Cr/
O iRS NAME. PHONE: CO L OR'S NAME: LIC NO: NYC CONTROLp
-3/O-S9 — <
AKCIIITECgErvGINEER: LICNO: ADD ❑
O T /Y
CONTACT: PHONE: QTY. ELE IC PERMIT ' FEE BUILDING PERMIT INFO
BLDG ELE-yCT PLUMB MECH
��T
PERMIT ISSUANCE TSA ❑ ❑
LICENSED CONTRACTOR'SDECLARATION APPLIANCES-RESIDENTIAL ��IOB DESCRIPTION
pyZ (hereby vffirLI than lson EDS DECLARATION
9(commencingwiN Y
¢00 Section 7X)0)of Division 3 of the Business and Professions Cade,and my license is in PANELS
al--1, full fuCant effect,
1y
< a 1,iccnse Cl. Lic.# UPT 200 AMP
N?y Dale COnnuClm MI
Z O,NZ ARCHITECTS DECLARATION O 1 S SQ.FT FLOOR AREA $/SQ,FT.
0 Z_p I understand my plans shall h molds public records.
FW
SI SELECf1tI
Liacnud pralnsinnul
ow, OWNER-BUILDER DECLARATION PECIA NIT/MISC.
kOe. I hereby affirm(hal I sm exempt from Ne Cmarecaors Licertm for e
W�Oy following re...u.(Section 1031.5,Business and Professions Cade:Any c ore t .METER OR POLE MST.
F'�w� which require,a permit in can me%eller,improve.demolish,of repair y sit cwre
oprior to iu issuance.also requires theapplicant I...ch,maiuofileasi ed ¢men, POWER DEVICES
,,<o p ,ha,he is licensed pursusn,to the provisions of the Comnnor's License law(Chapter
9(commencing with Section 7")ofDivisim 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
W_H or that he is c.corm therefmmand the bions far tneallegedenemplian.Any violation of OUTLET'S-SWITCHES-FIXTURES
C Z Q Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penally of �a�
KFonot more than five hundred dollars($500). O C/A
❑ 1,asowneroflhepropony.ormyemplayceswithw,ec,utheir compensation. NEW RFSIDENTLLLELECTR _%EL STORIES TYPE CONSTRUC11Ot
y3 will Jnthe wmk.and the sWaurcisnot intended proffered fors 5�(( Cce 044,Business
and Professions Code:The Contractor's License Law does�
or
apply 1 an owner of
property ximouildsorimproveadhercon,and whoduessuero ukhimself Ihroughhis
hoemployeea,provideethet soon improvements�iolen ledofoff, �r sale.IL OCC.GROUP RFS.UNITS
wever,the building or improvement is sold.(viTm one yourofcomplelion, eowner- TOTAL:
M1uilJm will have the burden of prpvn tharhe did ern huilJ or improve fore se of
sale.). TY. PLUMBING PERMIT
❑ Lasownerofthepro y,emesclusivelyconlractingwithlicensedcont owner-
are
Q FEE FLOGO ZONE qpN
construct the project(Sec 1Bt4,Business and Professions Code:)The Courfor rs
License Law Jnes not apply nenowneroffeapenyambuild orimprovestherepgtnd PERMIT ISSUANCE
who convan.a fnrsuch proje swish acommdor(s)licensed pu uanuolhe Comructnr's
License law. ' ALTER-DRAIN&VENT-WAl'ER(EA) FEE SUMMARY
❑ lam exempt under Sec. PC BACK FLOW PROTECT.DEVICE MSIDEFEM
Owner Dyte SANITARY YN
WORKMANC PENS D LARA DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
❑ I herebyafGrmtha,lhaveacer ificl mmulLi i race 'leme of SCHOOL TAX Y N
Workers Compensation Insurance or amt yther�j(N�.381XI, CJwhich FlXTURLS-PER TRAP RECEIPT
rcoves all employee's under this pmmi yVT) PARK FEE Y N_
Policy n _
GAS-EA.SYSTEM-1 INC.40I1TLETS CEI
Company-
0
IImPanY / BUILD( DIV 10
❑ Certifiedcopyishemby famished. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
CICciifiedcopyisfiledwilh Ne city ins don divisi GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE L
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
or le".)
ifthepetmae i,ismer hunerNdollars(SIM) SEWER-SANITARY-STORM EA,200FT. IN J
I certify that in the Performance of the work for which this permit is issued,)shall WATER HEATER W/V[iNT/ELIiCI'li
not employ any person to tiny manner sp as to become subject to the Workers PAID
Z Compensation Lawsof Califumia. Date WATER SYSTEMrrREATING Date Receipt#
Applicant
z 0 NOT ICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENT IAL PLMB. SQ.FT.
Cl� become subject a the Worker's Compensation provisions of the Labor Code,you must TOTAL:
foMwith comply with such provisions or this pemdt shill be deemM revoked, BUILDING IT-E
LU CONSTRUCTION LENDING AGENCY SEISMIC FTSE V
a z I hereby effort that hem is a construction lending agency for the perf morance of
UO ,he work for which this permit is issued(See3091,Civ.C.) TOTAL: T:LF.CTRIC II'iC
Iuendcrs Name
U.
U I<nder'e Address QTY. MECHANICAL PERMIT FEE PLUMBING FZ
1 cenity that 1 have read this application and slate[bat the above infonnmion is
0. correct l agree to comply with all city and county ordinances and slate laws mlaling to PERMITISSUANCP. MECHANICAL .E �#
_ (A building construction.and hereby authorise reprommativeso(this city in enter upon the _
U Z above-mentioned property for inspection proposes, ALTER OR ADD TO MECH.
CONSTRUCTIO TA%
(We)agree to save,indemnify and keep hannlesa the City of Cupcnino ageing
liuhilllies.judgments,coat nndexpenseswhichmayinanyway acerueagainnmid City AIR HANDLING UNIT('1010,00so CFM)
In canse�ft,4ce aft ing of Nis pe
�
AIR HANDLING UNR(OVER IO,gIp CFM)
Signature App a ungill
acp Date EXHAUSTHOOD(W/DUCt
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,000 BTU) Date Roveiplp
Will the applicant or future building occupant store or handle hvardous material
m defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU)
Coda,Section 25532(.)1
❑Yes ❑No VENTILATION FAN(SINGLE RGMD)
Will theaPplicant or future buildingacu tame BOILER-COW(3HP OR IMSW BN) I SUANCE T
pan qea Air ualityc Management
�e 1d
Nonni? air contaminants as define)by the Say Arca An Quality Managcmcnl BOILER-
I Dlntrin'7 COMP(OVER 100,000 NTLI)
❑Yes ❑No NEW RESIDENTIAL MECH, SQ.IT. ►31994
1 have read the haeardous materials oun ircmems under Chapter 695 of the I� 6
California Hovel h&Safe',Code Sections 25505,25533 and 25534. I undersmad that
if the building docs not currently have a moan,that it is my responsibility to notify the `� V
O cupanl of the rtquircmenu which min be me,prior m issuance of a Certificate of icy sur
Occupancy. Ur
Owner ur amhnrmed zgem Dale 1' ISSUED BY:
OFF1