26688 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRUTA-1. PERM["1'NO.
APPLICATION/PERMIT PLUMPING-MECHANICAL. 26688
BUILDING DIVISION BUILDING PROJECTIDENI'I FICA'I'ION
BUILDING ADDRESS: SANITARY NO. APIT
PLICATION SUBMITTAL DAT:
to QQ f—z y UNIT# LOTH
OW :RS NAME.: PITOSZ�� N'�ACTOR'S NAME: LICNO N/C KO #
LFC14 a Le
J ctf
�ARGI[ITIiGT/E GINF.Eft: LIC NO: A OKFS ❑
z ;Jr a� e
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT PEE
RLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACTOR'SDECLARol ATION
APPLIANCES-RESIDEN'GAL
WOOMatz Ihereby
in'DiothaU am 3(if th Bu inns and forame rmasCode. (co mmecense with IOIi DIiS
Wr00 Smtion'/000)of DlvlinnJ of the Business and Rofeesl,nr Code.and my license is in PANELS
tY V fall force and effe
FZW Licuuve 11�� Lic.# L� UPT02MAMPS
rn?y DateCommmur 201-III(p AMPS
ZOyZ ARCHITECTS DECLARATION OVER 1qp AMPS SQ.Fr.FLOOR AREA $/SQ.FT.
O Z—p 1 understand my plans shall be used u public records.
F y k W SIGNS ELECTRICAL it
Q-W L¢'enseJ Professtonel
aJ W OWNER BUILDER DECLARATION ON SPECIAL CIRCUIT/MISC,
�Oy V I h,rcby affirm thin 1 um cncmpt from the Gmnnear's hleanso Law for the \I /y \
u13 W Hollowing reason.(Section 911313,Business and Professions Code:Any airy or county TEMP.METER OR POLH INET. P
F
1q"Cs1�� which requires a permit to construct,alter,improve,demolish,or repay any structure 'NV
WW>- to its issuance,also requires the applicant forsuch POWER DEVICES t „ J
�� Prior t pp Permit Lic,signedstaamen. v I u
W tY p that he is licensed pursuant fruits provisions of the ContrecmCa License Law(shaper
9(rommencing with Section 7000)of Division 3ofthe Busincx and Professions Code) SWIMMING POOL.ELECIRC DATr
VALUATION
w Mae or that he is exempttherefrom and the basis for the alleged aemption.Any violation of OUTLET'S-SWITCIIIS-FI S
F❑Z Q Semi,n 903 LS by any applicam for a pemtit sobjcets the epplicam m o civil penalty of
L_FEp mtmore than five hundred dollms(5500). NEW RESIDENTIAL ELLCT'R 5 IT.
9 ❑ I,asowneroftheprnperty,ormyemployeeswithwagesusthelraolecompensatiit. Q� STGRIESY TYPE CONSTRUCTION
will do the work,and thestructure isnot maadedur,ffcred fnfside(Sec.]044,Business
and Professims Code:The Cmarranors License Law does not apply a an owner of
property who builds or improver thereon,and who does such work himself or through his
employees,pmvidedthmsuchimpmvementsamnotinandedarofferedforsale.IL OCC.GROUP RES.UNITS
however,the building or improvement is sold within one yemaf completion,the owner. TOTAL:
builder will have the burden of proving that he did not build or improve for parpue of
sale.).
❑ I.......ftbe property,aroeaclusively contracting,thlicensacmdar,mrsm QTY' PLUMBING PERMIT FEE 11.00D ZONE UNITS
construct the project(Sec.700,Business and Rofessime,Codc:)The Contractors
License Low does not applym an owt¢rafpmperry who builds nrimprovesthereon,and PERMIT ISSUANCII
who contracts for such projects with o mmenctor(s)licensed pursuun0o the Contractors ALTER Law, DRAIN&VENT.WATER(BA) ,FEE SUMMARY
❑ I am exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE ou-Shnn'EUS
SANITARY Y_N
Owner Dat° DRAINS-FLOOR,ROOF,AR EA,COND. RECIiIITp
WORKMAN COMPENSATIONDECIARA'UON SCHOOLTAX Y_N
EJIhemby affirm thaelhaveecmificaee ofcomunn,selLinsure.or•cenif¢au of FlXTURIS=PER TRAP RECHI Pr#
Workers'Compureaeion Insurance or acenified copy therenf(See.3800,Lob C.)which PARK IEE Y_ry'_
covers all employee's under this permit.Company
GAS-EA.SYSTEM-I INC.4 OUTLETS RECIIIPI'#
PolicCp# BUILDING DIVISION FEES
❑
Col Certified!copy Le hereby furnished. GAS-EA.SYSTEM-OVBR4(EA) PLANCIHICKFER
on
❑ Ccdifietl copy is fled with the city inspection division. GREASE/INDUSTRI.WASTE INTERCEPTOR GRADING ITE
CERTIFICATE OF EXEMPTION FROM WORKERS' ORFASETRAP SOILS FE-Ii
COMPENSATION INSURANCE
("Thisuction need nut be completed side permit is foronehundreddollars($IN) SEWER.SANITARY-STORM EA.200fT. ENERGY LLE
or less.)
I cenify that in the farkrmmce ofthe work for whichthis permit is issued,I shall WATER HEATER W/VEN'ToRLECIR
not employ any person in any meaner so as to hecome subject at the Workers, PAID
7-. ^onlpceti^atinn laws of Califomiu. Date WATER SYSTEMJREATING Date Receipt#
P
z0 Nor]ICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PI.MB. SQ.tet'. TOTAL:
G become subject m the Workers Compensation provisions of the[.shot Code,you must
� > forthwith comply with such provisions or this permit shall la,deemed revoked. BUILDING FEE
y 0 CONSTRUCTION LENDING AGENCY SEISMIC LLE
Z I hereby affirm that them iso construction lending agency for he performance of
V O the work for whichthis permit is issuedger.3097,Civ.C.) 1ELECTRIC FEE
Lender's Name
ULeaders Address QTY. MECHANICAL.PERMIT, VFFE' BING FEE
I certify that I ve rel Ilia application and sone Char the above information is t correct. I agree to comply with all city and county ordinances and sae laws relating to PERMIT ISSUANCEANICAL FEEbuilding construction,and hereby outhonae representatives ofthis city to enter upon thef,) Zabove-mentioed property for inspection fortioi ALTER OR ADD TO MECH. RUC1ONTAX(We)egress m save,indemnify and keep hamde is the City of Caperton,against Iiubilities,judgments.costsand expenses whichmay in any way accrue against said City AIR HANDLING UNIT(TO 10,OfID CFM)inconsequcn oft Iingoi � �-���Yl/ AIR HANDLING UNIT(OVER 10.000 CFStgn nae ofAplauca mmamr D e EXHAUST HOOD(W/DUCT)
I IAZARDOUS MATERIALS DISCLOSURE HEATING UNH(10 100,000 BTU) home Receipt p
Will the applicant or future building occupant smrc or handle hicnrdous material
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code,Section 25532(,)9
❑Y. ❑No VENTILATION FAN(SINGLE RESID)
Will Iain co icrniyrfutua repair]by he ay Am.Air Quality
BOILER-COMP DIIP OR IN,"BTU) ISSUANCE DATE
broader? air comaminents es Jcfincd by the Bey Aau Air Quoliry Mmagement BOILER 100,000 BTU)
UianicIT
❑Yes Cl No NEW RESIDENTIAL.MECH. SQ.Fr. PA
1 have rend the Safety
Code.mmennls requirements under 34.1 Chapter understand
,f the ���
California Hwhh&Safety CWyhavee.Sections ed,that
tit is add25534.1undersond Nat > as
if she building does not currently have a tenant,that r is my redave oiliry a notify the 6 1
Ocupent,f the requirements which most be mess poor b issuance of a Cenifirea of Ci Y
Occupancy, tr � r
Owneroromhonmd a gent Date TOTAL: ISSUED RY: /
OFFICE