26518 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO ,7I A' PERMIT NO,
APPLICATION/PERMIT PLUMBING-MECHANICAL !�C �a� O
BUILDING DIVISION RUILUINGIBOJF.C'I'IDI?M'IF'ICA'1'ION Go 10
RUIL/fDING AIJIJ ESS: - �� SANITARY NO. APPLICYDONSUBMITTALDATE
r
OWN RS NAMIi: `L'l10 CO CfOR'S fJAME: LIC NO: R� _\
3 hVI 1v NIC CON ROLM
•ARCIII'i'IiC /E G1NEL'R: LIC NO: ADDRESS: 1^� C ' ❑
CONTACT: PHONE: a ` BUILDING PERMIT INFO
O♦^ IG ,., l / // G QTY, ELECTRIC PERMIT FEC
J!a/` F7lO V ,BLpp EL-CI' PLUMB MECH
PERMIT ISSUANCE 71� 0
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
❑00 I hereby7")of
that l3 of th Business
n ss and irofes ions Coder add mmecense with c
4100 Sectforcea ).f Divisian3of she Business and Professions Code,and my license is in PANELSad fall WP
H W License Class Lis.p UP TD 200 AMPS
w�y Dam Contra, 201-1000 AMPS
zOyz, ARCHITECTS DECLARATION OVER I000AMP5 SQ.FT.FLOOR AREA M.FT
O2—❑ Iundemm�J my plans shall be usedos publicrecords.
r tot W rofeSIGNS ELECTRICAL
f+ Licensed Pssional
000 OWNER-BUILDER DECLARATION SPECIAL CIRCl11T'/MISC.
.°�Oc. 1 hereby offimn that I am exempt from the Contractors License Law for the
t+� P00 following mavan.(Seldom 7011.5,Business and Profasiom Code:Any city or county TEMP.METER OR POLF.INS'T.
Swhich requires a cro it to consumer.aller,improve,demo]ish,or repair any structure yyyK °
N2 poorer its issuance.also marines the applicant for such Permit to file a signed statement POWER DEVICES
p0 that he is licensed forward India provisions of the Contrmvors License U.(Chapter
0.0 9(commencing with Section 7")of nsudoo3ofthe Busimssand Profeasions Cale) SWIMMING POOL ER
LEE V L A ON
XW M,, .,that he iseount therefrommdthe basis fortheallegedem
ea ,tion.Aay vialatiwidf OUTLL'1'S-SWITCHES-FlXTURES
ZQ Section 9031.5 by anyapplicant forapermitudjim.theapplicaanoacivil Penalty of
not more'low Eve hundred dollars($501q.
SS❑ NEW RESIDI?NTIAh ELECIR —SQ.
FPo ❑ othe..k,.dtpstorem ormyempended or.fwagam theirsm compensation, Q L ° ONIFS ff
UCr10N
C3. will dotheandthe shuctureisna intended ofwdoesficall of applyA014,Bnerof r-F �,
ness
and Professions Calc:The Commemre License Low does not apply to on owner of /
property whobuildsorimprovesdamon,and whodas suchwork himrelforthrough his
emp]oyees,provided that suchimpmvemcnsmenotimendedoro(feted foreale.If.
_ OCC.GROUP TS
however,the bei(ding or improvement is sold within one year of completion,the owner-
builder will have the burden of that he did not build at improve for u of TOTAL:
prnvin8 P purpose
ale.).
❑ ],as owncndthe propemy,nm exclusively contracting with licensed contractors to QTY. PLUMBINGPERMIT FEE FLOOD ZONE
construct the project(Sec.]014,Business and Professions Code:)The Contractor's
License Lawdasnm apply tow ownerofpropmy whobui]dsaimproves Nenow,and PERMIT ISSUANCE
whocnmmc's for such Projects with acomntnm(s)licensed pursuant to the Contmmor's ALTER-0RAIN&VENT-WATER ILA)License Law. ( FEE SUMMARY
❑ I um exempt under Sm. ,B&P C for this reason, -OUTBACK FLOW MOM=DEVICE . DE S
SANITARY Y N
Owner Date RECEIPT,
• DRAINS-FLOOR,ROOF,ARM,COND.
WORKMAN COMPENSATJONDECLARATION SCHOOL TAX Y N
,erma'Couumoutiothat lurance or i owifiectile copytheort oof(Sesurgor aids C.) to ofwhich
FlXTURES-PI?R TRAP RECEIPIp
,asrkem'Compcnmtion Insurance oraccmifcdcopy Nertof(Sec.3900,Lab CJ which PARK FIiE Y N
coven a 11 employccrzalndc petfsit�9/J� p 2 GAS-PM.SYSTEM-I INC.4 OUTLETS RDIV?SION
Policy N L``]] ITL-----�� `777 95 BUILDING DIVISION FF.I?5
Cm
0 Certified cwyahi f GAS-M.SYSTEM-OVER 4(M) PLANCHECK FEE
❑ Certified copy is TIN with the city inspemion division. GRtiASG/INUUS'1'RL WASTI?INTERCfiI'I'OR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS MH
COMPENSATION INSURANCE
(This section need not be completed if the Permit is for one hundred dollars([100) SEWER-SANITARY-STORM M.2001T. ENERGY FEE
or less.)
I can if don in the perfmnows,of the work for which this permit is issued.]shall WATER HEATER WNENT/ELFM
not employ any person in any manner so at to become subject to the Workers PAID
Complain..Laesof Cnlifomio. Date WATER SYSTFAIMI?ATWG Date Receipt,
Z 'Z Applicant
0 NOTICETO APPLICANT:If,otter making this Cenifiwm of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
f~
'4 hmome subject o the Workers Compensation Provisions of the Labor Code.you must
forthwith enmply with such previsions or this permit shall be deemed revoked. BUILDING FEE
0, Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
=) Z I hereby affirm that there is a mnstrvctionlending agency for the Performance of
U the work for which this permit is issued(Sec.NKP.Civ.C) TOTAL: ELECTRIC FEE
Isndeta Name
F Lender's Address QTY. MECIIANICAL PERMIT FEE PLUMBING FEE
U 1 certify that I have read this application and sure that the above information is
ra correct. ]agree mcompl hall city and county oNimances and sum laws reading m PERMIT ISSUANCE. MECHANICAL FEE
C) huildingaadi-mli.a,andhe by authorize reprcsenmtives ofthis ciry'0enter upnn'he
L) z alive-mentioned property rinspe tionpurpases. ALTF.RORADDTOMECH. CONSTRUCTION TAX
(We)agree m see mem cep h ass Ne City of Caliendo.again['
liuhili'i`e udgmema six. 11 su.which y in my way oecrueagaiot sold City AIR HANDLING UNIT(TO 10,(1110 CFM)
to
in mnscgauce of ego. pe PIR HANDLING UNITIOVER 10,000 CFM)
gn of AppliconUC recta Date EXHAUST HOOD(W/DUCG
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,00IBTIH Date RIT. 11
Will the applicant or for=building occupant store or handle worardous material HEATING UNIT(OVER I00.00D BTU)
m defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 255320e)7
C3 Yes NNo VENTILATION FAN(SINGLE RESID)
BOILER-COMP(JHPOR 100,000 BTID ISSUANCE D E
Will tan exicantorlumre&ilow by then Bay Ampmen Qualitc Management PAID I
hazardous
uza ct'? yr wmeminenu m defined by the Bey Arta Air Quality Management BOILER-COMP(OVER 100,000 BTU) V' GN
Districs7
❑Yes I&No NEW RESIDENTIAL MECH. SQ.PT. ,AO BA 'I Qaa#a�
I have read the hazardous mmeria]s requirements under Chapter 6.95 of the Qjs l�LL d 1V99
California Health&Safety Code,Sections 25505,25533 end 25534. I understand that 'fes
Hine
ccupant oftheasnmconts which
mustla,Nate ismynuance biLtymnmur the CI11 Ut (aurcNllN
occupant of the requirements which must Foe met prior to ow,ace of a Certificate of
Owner or authorized agent Done TOTAL: ISSUED OY;�_(„
OFFICE