26962 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - a p PERMITNO.
BUILDING DIVISION APPLICATIONIPERMIT BUILDING PRROJECTOJECTPLUM MECHANICAL IURN'1'IFICA'TION 26962
BUILDING ADDREESrSS: /4- SANITARY NO. APPLICATIONSUBMI TALDATE
021 aj 9-Z N.1 V UNIT# LOT �1
OWNERS NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
e 1 s+ 1 Z_ ` N!C CONTROL#
�RCHI'HiCT/ENGINEFR: LIC NO:� ADDRESS: CS El PHONE: I�
QTY. ELECTRIC PERMIT ITE BUBLUING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ 11
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
I herebyuffirmthat I am IicensW underpeoviaionsofaapter9(commencingwith
-,0µ]0[ Section7")and ff Division 3n(the Business and Professions Code,outl my license is in PANELS
ty V u full force and effect
<ZW Licen las] G� Lic.p7 7aa UPT02MAMP3
ti<6 DaleCnmrv[mr�NC 201-1000 AMPS
F'z ARCHITECTS DECLARATION SQ.FT.FLOOR AREA 0Q.FT,
OZ^Q I understand my plans shall he used as public records. OVER IOW AMPS
� Q�
W.�{j SIGNS ELECTRICAL
Licensed ProRssiomal
< OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
OAU I hereby affirm that I atm exempt from the Confiscates License Law for the
3tr.y following TCMP.METER OR POLE INST.
grenson.(Section 7031.5,Business end improve,
deians Code:Any city or county
�I'a>-g which requhesaperninocmresthe pplicampmvah perrash,ar,a sig ed tWemre
�rp�Y� priormits Issuance,visa re9uims the applicantfmaucM1 pemtiuo file.signed statement POWER DEVICES
ou G 0 shut he is licensed pursuant at the provisions of the Cantracmes License law(Chapter -
a off 9(commencing with Section TNA)of Division 3 ofihe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
_ao or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OIITLETh-SWITCHES-FIXTURES
Za Section 7031.5 by any applicant for a permit subjects the applicant o a civil peoulty of
not morethe.five hundred dollars(S5W). NEW RESIDP.M'IAL ELECTR
o ❑ 1,oownerofthepropeny,ormyemploymswiNwagesastMirsolecompensation, —SQ.FT. STORIES TYPECONSTRUCTION
x300 will do the work,andthe structure isnot intended moffeend hassle(Sca.7044,Business
and Professions Code:The Contractors License Law does not apply to an owner of
proper whobuilds orimproves thereon,andwhodws such worhhimselfmthroughhis
OCC GROUP RES.UNITS
own employees,permitted throve impis sold nthin not earof ompleered finseletheow.If,
howeer will building a Improvement is sold within one yea or improve
omm a far f purpose
f p
builJer will have The burden of proving that he did not build m improve for purpose of
CIa
I,aswnero0he pmpmns
eny.aexclusively contracting with licensed commartonto QTY. PLUMBING PERMIT EE , LOOD ZONE APN 1
comtruct the project(Sec.7044,Business and Professions Code:)The Commences PERMIT ISSUANCE 1
License lawdoes not apply loan ownerofpropeny whobuilds mimpmvesthereov,and
who comms for such projects with acormactur(s)licensed purxuam to the Commences ALTER-DRAIN&VENT-WATER EA
Licatse Law. ( ) FEE SUMMARY
❑ 1 am exempt under 3u. ,B&P C fm this reams RACK FLOW PROTECT,DEVICE S ..S
SANITARY Y N_
Owner Data DRAINS-FLOOR.ROOFAREACONDRECEIPT#
WORKMAN COMPENSATION DECLARATION . , . SCHOOL TAX Y N
❑ thereby aft that l have a ccnificae ofconeenno self-insure,or a ccnificae of FIXTURES-PER TRAP RECEIPT#
Workers'Compenwion lmpmme or a unified copy thereof(See 3801,Lab C.)which PARK ME Y N
'.ures tl ttnyl¢ye4'synde y32 —03 BUILDING DIVISION FEES
a /�W(� GAS. INC.40UTLCTS
Company t�v—GO,— GAS-FA.SYSTEM-OVER 4(EA) PLANCHECK FEE
�❑ Cv iOeA meby fumishcd.
rtilied copy is filed with the city inspersion division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOfLS FEE
COMPENSATION INSURANCE
(This section need not becompleted lithe permit is forone hundred dollars pi IW) SEWER-SANITARY-STORM EA.2al ENERGY FEF.
or lexa)
I unify that in the performance of the work for which this permit is issued.I shall WATER HEATER W/VENTIELFC'IR
not employ any person in any manner so as at become subject to the WorkersPAID
Compensation Lawsof Califomia Date WATER SYSTEM/TREATING Dam Receipt#
O z Applicant
O NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
F (A become subject..he Wonces Compensation provisions ofthe Labor Code.you must
� , forthwith comply wit such provisions or this permit shall be deemed revoked. BUILDING FEE
[] CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herehy.fion he, iso caromction lendingagency far the punforn cot
V z TOTAL: ELECTRIC FEF•
O the work fur which this pcsmit is issued(Sec.3097.Civ.C.) .000
Lenders Name
u-' F lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING PEE
O V I certify that I have read this application and state that the above information is MECHANICAL FEE
>" L2•I correct.l agree tocomply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
F' a' buildingeonstrursion,and hereby suthoriae reprsacroaives offlaselty former upon the
U Z abase-mentioned for ins lm.purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
PataveY if P Rtes
(We)agree to save,indemnify and kap harmless the City of nst s against
Iiebilities.juJgmeme
s,cosm and which may loony way accrues against sail Cry AIR HANDLING UNIT(TO 10,000 CFM)
in comseyuenes of the granting of this Permit.
AIR HANDLING UNIT(GVHR 10.000 CFM)
Signature of ApplicanVConmarsm Data EXHAUST HOOD(WNUCT) PAID
HAZARUOUS MATERIALS DISCLOSURE HEATING UNIT(TO UXLW BTU) Data R ecusn N
Willthcspplicant orfuture building occupant tom m handle hazardous material HEATING UNIT(OVER IW,001 BTU) TOTAL:
us defined by the Cupertino Municipal Code,Chapter 9.12,and The Health and Safety
Coda,Section 25532(x)7 — / VENTILATION FAN(SINGLE RHSID)
13 Yes Y a
ISSUAN E DATE
Will the applimentorfoture buildingoccupaut useerulpmenfordevices whichemit BOILER-COMP LIHP OR IM."BTU) V dA U
huncelms is contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER Hat."BTU)
District? 13 'I 1994
Yes � NEW RESIDENTIAL.MECH. SQ.PT. SEP � I
I have read the hazardous materials rquirements under Chapter 6.95 of the _
C.lifomie llealth&Safety Coda Sations 25505,25533 and 25534. 1 undrmmnd that CITY Ur GUrrm 1 r�I 1
-ILIbe building dons not currently have a[count,that it is my responsibility to notify the
occu of the ems which must be sun prior to issuance of a Certificate of
cup
rem o Data TOTAL: ISSUED BY:
OFFICE