26635 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PERMIT No.
BUILDING DIVISION APPLICATIONIPERMIT BUILDING
PLUMBING OJ-MECHANICAL 26635
CT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLIaC'A�TIOON�SURMI'ITALDATE
UNIT# LOT
OWNERS NAME: PHONE.: �/
COW ,WEUR'S NAME: LIC NO:
NIC CONTROL
eSN 6a �rYC.S EJ r l� ENAN
f
AW-HJT[LUJESGIN2IM LIC NO: ADDRESS: ❑r � +� s (�acmtS C12/6, 07�/�✓/✓lp r<D Av£. S�wcE
CONTAMT PHONE: BUILDING PERMIT INFO
QTY. + ELECTRIGP,ERMIT _ FEE
PERMIT ISSUANCE r BLDG L PLUMB MF.CH
is
ICENSED CONTRACTOR'S DECLARATION pppL1ANCB8- 1 IAL JOB DES PITON
Maltz IhambyafGrm that l sus licensed under provisienc
onsofCTapter9(comming with
❑100 Section 7")of Division 3 of be Business and Professors Code.and my license is in PANELS ,
y W full farce and effort C 1
<F z W License Class Lic.# 2 1 1
rn=y Date Cantnctor 2 SQ.FT.FLOOR AREA S/SQ.IT,
ZOnV 1 MPS
2 ARCHITECTS DECLARATION -
O Z—G 1 understand my plana shall h used es public recoNs.
oz!ZW—a AUksP.LECfiTICAL
QS'�d-dE; Licensed Professional ARA
N'O
ot< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
�x�da V I hereby uffom Net I um exempt from the Convenors Limns Lew for the
rs13arFlion 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE MST.
Oa following rcason(SecJ which requires a Permit to construct,alcor,improve,demolish,or repwr any structure
KQ� prior to its issuance,also requires the applicant for such Formilto file asigned statement POWER DEVICES OO
stiller p Nm he iscngwpursuantto Neprovisionsof Ne Comments Lim Lew(shaper
SWIMMING POOL ELECTRIC
d e 9(commencing with Section]lIW)of Division Sof Ne Business and
Profession Cade) ALUATION
W_m rr shot he is exempuherefmen and the basis for thealleged exemption.Any violation of ��.,.
tZG Section 7031.5 by any applicant for a permit subjects the applicenuoacivil petWty of ITfLETS-SWITCHES-FIXTURES
Ea G
not mom than
,.fthemperty,ormyem). NEWRFSIDENTIALELECTR _SQ.FT. STORIES TYPE CONSTRUCTION
W � ❑ othewrk.andeprotractiormyemployceswdhwagaas Nei(Sec.7(ii Buadan,
L
will dotheandthe Slmcmreisnm'sLicese Law
fs act apply
Loan Bus
ss
and ertywhiona Cade:The Contactors License Lew des not apply lf an owner is
progenywhobusIdsorimproves Nereoo,endwho acessuch work h itselfortlooughhis
own empinycea,provided Nut such improvemcnnare notinrtndedoroffemA Tarsale.If, OCC.GROUP RFS.UNITS
however,the buildingor improvement is sold withintae yearofcompletion,the owner- T
builder will have the burden of proving dim he did not build or improve for purpose of
Sala')' QTY. PLUMBINGPERMIT FEE FLOOD ZONE "N❑ haaowner rfNe propeny,omexclusivelyconveding with licensed convmtorsto
construct the project(Sec.7044,Business and Profusion Code:)The Contractor's
License law does not apply to an owner ofproperry who builds mimprovesthereon,and PERMIT ISSUANCE
who contacts for such projects withscoutmnor(s)licensed Formulator the Convector's ALTER-DRAIN&VP.M'-
LicenseLaw. WATER EA) 1 at ft 111 FEE SUMMARY
❑ 1 em exempt under Sec. B&P C for this won '
BACK FLOW PROTECT.DEVIC t �t �„
TA YN
Owner Dore I RECEIPT#
DRAINS-FLOOR.ROOF,AREA, O
WORKMAN COMPENSATION DECLARATION ! g m Y N
I hereby affirm that l have a mrificee of consortia self-insum,ore certificate of I RFCEIPT#
bk C pe u Ins nfedcopy thereof(Sec.3800,Lab C.)which DXTURES-PF,R TRAP P YN
an ell ar mryee's under Nis permits it GAS.f .SYSTEM-I INC. OIITL• RECEIPT#
Policy It NODIVISION FEES
Company GAS-EA.SYSTEM-OVIM IPA) PLANCIIECKFEE -2-16r5, O
❑ Caddied copy is hereby famished.
❑ Certlfid copy is filed with the city inspection division. GRF.ASFANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not lib completed ifthe permit is foranehuvdeed dollen(51007 SEWER-SANITARY-STORM P.A.200FT. ENERGY FEE
m Ias)
I cattily that in Ne performance of the workfm which this Permit is issued,I shell WATER HEATER W/VEN/M.ECTR
not employ any person in any manner so as to become subject to the Worker' PAID
Compensation Lawsof Casidmain. Dae WATER SYSTENITREATING Data Receipt
0 z Applicant
z 0 NOTICE TO APPLICANT:If,after making this Cerdfcam of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
r-r V) beom
ce subject m the Workers Companies.provision of the Lelwr Code.you most
foMwith comply with such provisions or this permit shall he deemed revoked. BUILDING FEh Pal �e
W [a CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affimt that Nerc is o constrvchon lending agency for the perearnnu of
V 0 the work for which this permit is issued(Sm.3097,Civ.CJ TOTAL: ELECTRIC FEE �.
Lender' FE
Leader.Name -- �,:�. PLUMBING E
O U re
Lender 's Addrcas QTY.?t.ti, ;MECHANICAL PERMIT FEE
I canify that 1 have ad this implication and smut that the above information is i""" '
W cored Iagree to comply with all city sed county mdinuncesendsete laws relamin b PERMIT ISSUANCE MECHANICAL FEE
buildingconswction,andhembyauthod=mpnsenmfivaof Niscityroam-upon the CONSTRUCTIONTAX
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)ages m save,indemnify and kmp hermles the City of Cupertino againt
liabili0cs.judgmeno.coats andexpenses which may many way accrue against said City AIR HANDLING UNIT(TO 10,OW CFM)
in consequence of the granting of this Permit
AIR HANDLING UNIT(OVER 10,0011 CPM)
Signorine of ApplicangContmaar Date EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Receipt#
Will the applicant or future building occupant store or handle hazardous material ❑EATING UNIT(OVER 100.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,end Ne Health and Safety
Code,Section 25532(x)] ;(No VENTILATION FAN(SINGLE REBID)
❑Yes
ISSUANCE DATE
Will theepplicunmrfumrebuildingoccuPentuuequipment ordevica whichemit BOILER-COMP IMP OR 100,(100 BTU)
s air conmminaae as defined by the Bay Area Air Qushly Management BOILER-COMP(OVER 100,00)BTU)
❑Yes ANO NEW RESIDENTIAL.MECH.—SQ.PT. PA10
1 have mad the hazardous materials requirements under Chapter 6.95 of the C.�/�/�
if
Healthy Safety Code,Senior25505,25533 and25534. Iundemandthat e u t/ yy(t
California the building doer SIL ety Code,
haves mart that it is am 25534. 1 un a noddy the
mcupant of the isparemeals whic m A ba a prior to issuance of a Ce 'ficaze e, CITY=�1
C £ V er gs Er I
euth agent Data TOTAL: ISSUED BY:
OFFICE