26880 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BH.1Gi1G-nl.`�ITI A PRRMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJEC'1'IDEN'TIFICA1'1ON 26880
BUILDING ADDRESS: SANI'T'ARY NO, Tl�a799�k
9'LICA'TION
SUHHMIITI'AL DATE
�p$•�. ISN` o�►.�AN -.Its
�Jp�(Y UNIT/f#y��p/�O� �LO�T/�p�,�`y ^�M OWN'RS AM.. I"Irt IV rHONE ps-a— /JSCON' ali rig %,-WJE GMV'GLJ.v N��aLm" NIC CONIROL#
• RCHHRCT/ENGINEER: LIC NO: ADD/ V7o /I4ypa" /a& � '�
CONTACT: PHONE: V F M BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECII
PERMIT ISSUANCE 0 0
LICENSED
vkma EDCONTRA..and
APPLIANCES-RESIDENTIAL f �
pKZ (hereby affirm then lam licensed under CONTRACTOR
SDlnCLAiRAper9(commencing with
FOO Sectian]UTA]I of Division Jnf the 0usinns unJ Pmfnsions CUJc.unJ my license ism PANELS
aVF full fora and effect , UP T0200AMP5
U License Cln � I.ic.N "1
yQd Date I��Contra fYC/LT U 201-1000 AMT'S
FpN ARCHITECTS DECLARATION SQ.FT.FLOOR AREA` $/SQ.lel'.
7pN[a OVER IWUAMPS
5Z O underhand my plans shall he used as public cmrds.
F,yFu1 SIGNS ELECTRICAL y- r E D B 1
Q 4 Professional
fcssionvl
OKOWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. - l p
S
W I1 �I
p�Oo. I hereby affirm the 1 an exempt from the Convacmr's License Law Eats, LVJ U V E u
W3y 4following reason.(Sation]0315T E
.Business and Professions Cole:Any city or county TEMP.MER OR POLEINST.
16-19
,LL O Q which requires a permit to construct,alter,improve,demolish,or repair any swnure
E,:; wits i"Weare,also Thea licam for such ua file.si Whzmceat POWER DEVICES /-
prior requires pp permi gn ATE
WQ a Lha he is licensed pursuant to be provisions of the Commetors License Law(Chapter
� SWIMMING POOL ELECTRIC
9 tar,h en exc with amfou]000)he Division 3 of the ed exemption.
and .Any vons Code) VA`LUATI'O��
Wim Shen h7031.5 by any applicant
mmand the M1asisfaftbeallegedexempt to civil
of OUTLETS-SWITCHES-FIXTURES
FL¢ Section]03 LS by any vpplicam far n pemtit.wbjects the applicant m o civil penalty of
p hat more than flve hundred dollars($500). NEW RESIDENGAL ELL= —SQ.FT.
IY � ❑ I,asowneroftheproperry.ormycmployaswithwagcs asthcirsol¢ompcmation, STORIES TYPE CONSTRUCTION
ywill do the work,and the structure is not intended oroffered forsale(Sec.7W.Business
and Professions Code:The Contractor's License Law Jas not apply to an owner of
property who builds or improves thereon,and who dues such work himself or through his
employees,providedden such impom
vereesam not imendedoro(feted forsale.If. OCC.GROUP RES.UNI'T'S
however,the buildingor improvement is sold within one year of completion.be owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ I.asownerofthepmpeny,ameaclusivelycontmctingwitM1licensedcontractorsto
construct the project(Sec.7(W4,Business and Profeenions Cade:)The Convenor's
License Lawdoesnot apply mavownerofpropertywho builds or improves thereon.and PERMIT ISSUANCE
whoucnacm forsuch Willem with accounum (s)licensed pursuant o the CUmmelors
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 nm exempt under Sec. .B&P C for this rcnwn O TSIDE FEES
BACK FLOW PROTECT.DEVICE
SANITARY YN
Owner Date DRAINS-FLOOR.ROOF.AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARAI'ION SCHOOL TAX Y N
❑ lherebyafiinnthallhaveacenifrucofennsentlUulf-insure,orucertifcacaf FI%TURES-PER TRAP RECEIPTp
WorkersCompensation Insurance or a certifiedeopy themcf(Sce.3900,Lab C.)which PARK FEE Y N
covers all employee's under this pencil GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT p
Policy x BUILDING DIVISION WiFS
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHF.CK FEE
❑ Cenified copy is hereby famished.
❑ CcrrilieJ copy is fled with the city inspection Divisian. GRFASFDINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
('Phis ncaion need not be completedOthe permit is minor,hundred dollars($100) SEWER-SANI'T'ARY-ST'ORM EA,20011'. ENERGY :Ii
or le c
Icnify that mine perfonnana of the work for which this pcmtit is issued.Ishall WATER HEATER wNPNT43LF.C1'R
not cmpluy any person in any monncr so a bee bject to the Wofl e. P
Compcnsarion La In Catif mia. Dene sY WATER SYSfEM/rREATING Dam (Req),l
Z Applicant—Lu1. CSPEL. OOK.SFi e
Z 0 NOTICE TO APPLICAN'I`If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TA L:
p It become aubjed to the Worker's Compensation Provisions of[be Labor Cade,you must
forthwith comply with such pmvisians.,,his psmll shall h doomed me.ked. BUILDING FEE <7 N
W !3
CONSTRUCTION LENDING AGENCY SEISMICIF
1 hereby affirm that then is a commuction lending agency for the performance of
TOTAL: - ELECTR
U O
the work for which this permit Is issued(Sec.3097,Civ.C.)
Lenders Name PLUM GPEE
0 F Landers Address QTY. MECHANICAL PERMIT FEE
U 1 certify that I have mad this apilimmion and state that the above inf zonation is MECHANICAL FEE
>- W lWeer. (agree In comply with all city and county mrinance,taximme laws alining to PERMIT ISSUANCE
I" building construction,and hereby authorize representatives ofthis city reenter upm the CONSTRUCf10NT X
U Z above-mentioned pmpeny for impenian purposes, ALTER OR ADD TO MECH.
(We)agree m demnify and k p harmless the of Cupertino against �1
liubiliric,juJgmcn ,c hs and cnsmwM1ic ymany accrue against said City AIR HANDLING UNIT(TO IQOOOCFM)
ucnce of rami. thispe
AIR HANDLING UNIT(OVER 10,13(1(1 CFM)
Si atom of Applicnm/Ce1 sector Dene EXHAUST HOOD DGDUCID PAID
HAZARDOUS MATP.RIAI S DISCLOSURE HEATING UNIT(TO HY),WO BTU) Dwe Receipt#
Will the applicant.,future buddingoccupant store or handle hazardous mall HEATING UNIT(OVER 100,000 BTU) TOML
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safely
Code,Section 25532(q]
❑Yes P Nn VENTILATION PAN(SINGLE RESID)
ISSU NCE DATE
Will the applicant orfurum building occupant use equipmeneordeviceswAichemil BOILER-CGMP(3HPOR I OdO00 BTU))
hazardous air contaminants as defined by the Buy Area Air Quality Management
DomicR gO1LER-COMP(OVER 100,000 BTU)
O
❑yes Z1 No NEW RF,SIDENITIAL MECII. SQ.IT.
1 have read the hmardous materials mquircmems under Chapter 6.95 of the ASG 1719
California Health Cod04
Code.Sections 25505.25533 and 255 . I undersmndtbal CQ
ld
if the building does not cumeatly have a tenant,that it is my responsibility to notify the Y
ecupum of the rcyuiranenk which matt rte ton prior to issuance of a Cenificme of Vr
Oaupunay.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE