26567 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
A PERMIT NO. ^ ^ �.p
CITY OF CUPERTINO PLUMRINp:-MECHANICAL L LVA 1/
BUILDING DIVISION APPLICATION/PF.RMIT
BUILDING PROJECT IDENTIFICATION
BUILDIN1G ADDRAE/SS/� P1 TO SANITARY NO. APPLICATION SUflM/I yTTAL DATE
2l Wefm� \ Fri* UNIT#I` \O LOT# 3 �_� iW
OWNERS NAME: PHONE: CONTRACTOR'S NAME: L nNO: NIC CON LJ l
•ARCHITECUENGINEER: LIC NO'. ADDRE`SSu ` El
7'1 C 'F-n RvG PAil.o Act)
CONTACT: PyeNE: BUILDING PERMIT INFO
1/�4I QTY. ELECTRIC PERMIT FEE ,
ELAINE V0UL6F112,r-S -DI22 i , P9
ex—
PERMIT ISSUANCE l�''
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
❑zz Ihereby affirm that l mor licensedunder provismnsofChapter9(commencingw0h
{ 00 Section]0haof Division 3 of the Business and Professions Code,and my license is in PANELS
y�dzF f forceandeffect. 2� UP TO 200 AMPS
G O lata Lia#
.Fn Qy Ovte Convector (�SZ 201-1000AMP3 SQ.PT.FLOOR AREA S/SQ.FT.
z FO❑vcei� ARCHITECTS DECLARATION OVER 1000 AMPS
O z—q I understand my plane shall heated.,puM1lic records.
F,o,F W SIGNS ELECTRICAL
0� Licensed Professional
a OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. ,$I�-•
yy O y tJ Ihereby effimm that 1 an exemptthe from Comractors License Lew for the
Dxl3 Cy following reason.(Section 0031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST. —
E4Oy which requires a permit'.a..me,,alter,improve,demolish,or repair any structure
}� prion.its issuanm W
ce,alsorequires Ne applicant for such per .file.signed statement POWER DEVICES
G0 that he is licensed pursuant to the provisions of the Cmarmrors License Law(Chapter
SWIMMING POOL ELECTRIC VALUA9'ION
0 9 that he is(commencing thection refrom
and he basis
Sof the ed nsess andmptio Professions Curtis)
,n or that he is exenmpuhereftom and the basis far the alleged exemprion.Any vialadon.f OUTLETS-SWITCHES-FIXTURES - '
6 Section]031an
.5 by say applicant for a permit subjects the applicant to a civil penalty of J
t more than five hundred dollars(S500).
❑ NEW RESIDENTIAL ELECTR —SQ.FT. STORIES TYPE CONSTRUCTION
W ❑ ome wrk,and t pmpeny,armyemployeesmthwagesasthei(Sec.c.tnpnusin�,
p, willdothework,andthe he Certimeteris License La a does and
0044,Business O
and Professions Code:The Centimeter's License Law dans not apply to an owner of
ownertywyees,pdsmimprovesthimprovnmentsa notintssuch w&doroferedfrrsge.Is OCC.GROUP RES.UNITS
employees,providrimprvervanpis sold within
neyea foompftion,the O e.If,
however,the building.rimpr.vemem is sold within oneyemofcompledmn,the owner- Q
builder will have the burden of proving that he did not build m improve for purpose of
sale.). NLOOD—ZONE APN
❑ 1,m owner mine property,an exclusively contracting with licensed contractors'. QTY, PLUMBINGPERMIT FEE
onmruct he project(Sec.9044,Business and Professions Cm[W)The Conrrecror's
License Lawdoes not apply to an owneral Properry whobuildsmrimprovesdamon,and PERMIT ISSUANCE �a
Who contracts for such projects With a contracter(s)licensed pursuant tothe Contractor's ALTER-DRAIN&VENT-WATER Ih) FEE SUMMARY
License Law.
❑ I nm exempt under Sec. ,B&P C far this reason BACK FLOW PROTECT.DEVICE O SIDE FEES
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA,COND, RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑• Iberebyaffirm that l have a cruffica'e.fconsen'to stlf-intme,Or a ardficate of FIXTURES-PER TRAP RECEIPT#Workers'Compensation lnsonce macertifiel copy thercof(Sm.3800,Lab C.)which PARK FEH RECEIPT# N
m
covers all employee's under this permit GAS-EA.SYSTEM-1 INC.4 OUTLETS BUILDING DIVISION FEES
Policy#
Company GAS-EA.SYSTEM-OVER 4EA) PLANCHECK FEE O
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section neednm becomple'ed ifthe permit is parent hundral dollars($100) SEWER-SANITARY-STORM FA.200Ff. EN[iRGY FEE 2 O
.,leas.)
I certify dim in Ne performance Permit of Ne work for which this peit is issued,l shall WATER HEATER W/VENT/FLECTR
nut employ any pars^.in nay meaner ao as t.become subject 1.Ne Workers' PAID
Compensation Lawsof California. Date WATER SYSTEMORGTING Data Receipt#
Applicant
NOTICE TO APPLICANT:If,after making this CeCertificates,Certificates,of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
become subject to the Workers Compensation provisions of the Lab ��a!k
or Code,yea must ` BUILDING FEE W
forthwith comply with such provisions m this permit shall be deemed revoked.
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
UZ I hereby offimr that is a construction lending agency for the performance of ELECTRIC FEE
0 Permit the Werk for which this is issued(Sec.3097,Civ.CJ
Lenders Name PLUMBING FEE
u" F Lender's Address QTY.
MECHANICAL PERMIT FEE
CU I certify that I have read this application and state that the above information is MECHANICAL FEE
Y correct lugrec'o comply with ell city end coon ordina cera ds'am laws reledng'o PERMIT ISSUANCE /"'
F" ow7 mildingeommuction,and hereby andodzerepreseddives m ildis city to enter upon the CGNSTRULTIONTAX
U F7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of CLpce ino against
liabilities,judimacm,coms and expenses which may in any wayaame againm said City AIR HANDLING UNIT(TO 10,000 CFM)
conseque ce of the grantin of this permit.
�y, AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of AppliwnUComm or m EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt It
Will the applicant or future building occupant more or handle hazardous material HEATING UNIT(OVER 1W,000 BTU) TAI-'
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Sermon 25532(-)? VENTILATION PAN(SINGLE REBID)
❑Yes ❑No
ISSUANCE DATE
Will Naapplicanmrfumrebuilding oaupanmstequiprtWm ordevlas whlcheml'
BOILER-COME(3HPOR 100,000 BTU)
• hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100.000 BTU)
District? ❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. / ucr Z
1 have readIhe hazardous materials requirements under Chapter 6.95 of the O y}�,'`.'ff'' 1994
California Health&Safety Cale,Sections 25505,25533 and 25534.I understand that / Wh
if the building does not currently have a moan,that it is my responsibility to notify the
occupant of the requirements which mum he me'prior to issuance of a Certificate of
awv-icy. Fish
./1 /t♦
Owner or authorized agent Data q 1 ISSUED BY:
OFFICE