26435 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO nllu.DING-6Lbu RLCAL. PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. C �I C
BUILDING DIVISION BUILDING PROIF.CTIDENTIFICATION 64 J
BUILDING ADDRESS. III\ p� �'� 1l \\J SANITARY NO APPLI/G{r�'ION SUBMITTAL DAM
o 9 ) \ a'1�V.-.i-�,l���x1 \/� UNIT# LOTH - �j�? / I Z-/
0 NERS NAME HONE' _ COTCl/O�R'SNAME (L � LTC NO: N/C CONTR(((OL#
` W K�l NCrM��I � - �'�1� L.yyV��((l�G�-$�T1\�1\J�O AIUMf�IRU(r n �
\RCIIITF;CT/F.N(i1NEER I.IC NO I \CI!bc\ 1 YC�A V z11 goo.`wQ El
CONTACT PHONE
' QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INPO
- BLDG ELECT PLUMB MECH
PERMIT ISSUANCE I�
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
Ihereb ffirm that latn heensed under of 9(commencm with I JOB DESCRIPTION
p{ 00 hereby provisions per da,
Fq Op❑ Section c and e of Orvisi.n 3 of he Business and Professions Code,and my hernse Ism PANELS �D
, Lareareeand effect UP TO 200 AMPS gil- �r 0
yQz W Date Class Cl #
D ab Uutr C.mract� 201-1000 AMP$
ZOy Z, ARCHITECT'S DECLARATION OVER 1000 AMPS SQ FT FLOOR AREA $/SQ FT.
O�y„q 1 understand my plans shall be used as public records. R
Lmenail Professional SIGNS ELE T'RIl�4L• �i I a NIA
��p'� OWNER-BUILDER DECLARATION I SPECIALC1p2CU!C!SC.:" I� �I i
KOp�,F 1 hereby nitirm that I am exempt from the Contractors Lcense Lew for he U
W1 :0 foll.wmg reason(Section 70315,Business and Professions CirZArt nty"mfe,my TEMP.ME ROR LE T.
F K]m.¢4' when require+a permit to comtru.L alters Improve,Aemolish,or repair any structure
F. Y� priormitsis suance,alsoregmres theapplicantforsuchpermittofileaslgnedstntrment PGWERDB Ices DATE ��
Q O that he a licensed Transient to the provisions of the Contractor's License Law(Chapter
d(i,o�L 9(commencmg wM Section Division 3of We Business wd Propose.Cade) SWIMMING C C—' - - VALUATION
FF
WX M or mbar he ise\empt herefmm and the basis for he alleged exemption Anyvmlation or OUTLETS-SWITCHES
/./M/, D �•T
0
Section 7031.5 by any applicant for a permit
property,ms my c0mployea.whb the
als theutsuleenspenatronr D O
NEW RESIDENTIAL ELGCfR —SQ,FT. S'IyItPES TYPE CONSTRUC310N
ycee will do the work,north,structure......mended.rofEced for sale(So,7004,Busmesv
and PmEsv.as Code.The Contractor's License Law does not apply to an owner of
property who builds or Improves thedemonlwhoddes such work himselforthrougbhn OCC GROUP RES.UNI'T'S
own mployroe,inivded that wchim poderents are n.untendnd.,offered torsale IL
however,the building or Improvement is sold within one year ofcompletion,the owner. TOTAL:
budder will have the burden of proving that he did not build or improve for purpose of
ale) QTY.( PLUMBING PERMIT FEE FLOOD ZONE APN
❑ Las ownerofct(See dTLI,Business an caofetiio winlicensed CUntreclors to
whImams the protect(Sec om Btislae0 and Professions CMe.)The Cere.,and PERMIT ISSUANCE
ofeLaxdce,.,h apply eracts with whubstuddis paommpan the thereon,and
whocmmmmsfmrsuuhpm3eds with econtrectogs)licensed pursuam to the Cono-acmr+ ALTER-DRAIN&VENT-WATER(EAI
Ltonnse Law. I PEE SUMMARY '
❑ I um exempt under Sec B&P C for his reason BACK FLOW PROTECT.DEVICE DO SIIJE FEES
ISANITARY Y N
Owner _ _Date RE-91PTa
`' WORKAIANCOMPENSATIONDECLARATIQN DRAINS-FLOOR,ROOP,AREA, ISCHOOLTAX Y N
J�(hereby affirm lhmlhnveacemficate of consem mself-inwro,oracemficme of / Y� REr't,Pn#
Wn Aeri Compd Ww0onlnsuroveor stumped copy thenuf(See.38W,Lab C)which /O FIXTHRES-PER TRAP (PARK FEE Y N
.ever,all employee's under this permit. ( UILDING GAS-EA.SYSTEM-1 INC.INC4 OUTLETS ECEIP DIVISION FEES
»
Policy
Company (GAS-EA.SYSTEM-OVER 4IFAT PLANCHECK FEE
Cl Camped ropy is hereby fumished.
❑ Cerrfied copy is filed with the city inspection division. OREASBpNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE.TRAP SOILS FEE.
COMPENSATION INSURANCE
The'laten need cone completed lithe permit is future hundred dollars l$IWI SEWER-SANITARY-STORM EA,20017. ENERGY FEE
o h,".)
Icertdy thatmhe performance of the work for which lhlspernn lslssued,Isbell WATER HEATER W/VENT/ELECTR
not �any�Nmourner s aye bagrq suhteci r�the We*. AID
tNvwsuECalifomlL Qa� �- °mS�'-{1 WATER SYSTEMTREATING Dale Receipt#z Applicant z O NOTICE TO A`PPPLIICAAN'T If,aaferr`anking this Cend¢at—en Ex ptinn,yru sho.IJ NEW RESIDENTIAL PLMB. SQ.PT TO'T'AL
fn become a. ect1.the Worker's Cnmpematim provisions of the Labor Cale,you must - __
a ; Forhw perm
an comply with such Provisions or this pern shall be deemed revoked. BUILDING FEE
a (�
CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm hat[here is a construction lendmg agency for the performance of
U O the work for which this permit is issued(Sec.3Lw'/,Cis,C.) TOTAL O EI,F.CI'RIC PEE
Lender's Names
U Landers Addry= 'IQIN. MECHANICAL PERMIT FEE PLUMBING FEE �M 7QYL.
I wrh that I have read this application and s tem that he above information is -
r�" a hnrect Ingree mcomply with all city and mun[y ordinances and state laws relatmgm PERMIT ISSUANCE MECHANICAL FEE
building construction,and hereby oullamre representatives of his city to enter upon the CONSTRUCTION TAX
V Z above-mentioned property for mepectum purposes. ALTER OR ADD TO MECH.
(War agree to save.Indemnify and keep harmless the City of Capertmut against
liabilities,judgment%,costs and expenses which may In any way accrue Matinstsaid City AIR HANDLING UNITD'0 10,0W CFM)
In cmnseyuenne of the granting of this perm.
. NR HANDLING UNIT(OVF,R IU,000 GIT11 I
Sigroud of Appncam/Contra.mr Dam EXHAUST 11001)WIDUCH
PAID
HAZARDOUS MATERIALS RIALS DISCLOSURE.
HEATING UNIT I TO 10J."BTU) tat "ad"dN
Will the the upplurnat peror faun hipul C de,Chant store or handle hazardous d Safr material /O 9 e Of/
its Refined by the Cupertino M1lunicip.J Code,Chapter 9,12,and the Health and Safety HEATING UNIT(OVF,R I W,OW BTU( � TOt'AL.
Code,Section 25532(3)?
El Yes ❑No VENTILATION FAN(SINGLE RESTED
(BOILER-COMP(?HPOR IOO,WO BTU) I ISSUANCE DATE
Will the applicant or future budding oreupant use equipmert dr devises which emit .
• hazardous air conummants as deputed by the Buy Area Air Quality Management BOILER-COMP.(OVER 100,000 BTU) PAID
'
District? _
❑Yes ❑No NEW RESIDENTIAL MECH. SQ FT.
I have read[]in hazprdom mmenals requirements under P"Per 6.95.f the I MAY 2 7 1994
Cahf.mm lle.lh&Safety Code.Sections 25505,25533 and 25534 1 understand that
� he budding does not urend M1av nunl,hard le my responsibility In no[dy the
reof mr IN 1,x ch r c amt prior m issuan.e of a Cerhficare of
�2q Ll CITY Ur Ur IDry
Owneror auhorrze Date TOTAL.( ISSUfrld ��'h�
OFFICE 0