26570 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - a ILDI ..E DUCAL PERMIT NO.
^RmLDING DIVISION APPLICATION/PERMIT PLUMPING-MECHANICAL 2600
BUILDING PROJECT'IDEN'1'IFICA1 ON
BUILDING ADDRESS: y A6(0-'5-7
/_eco] ,s SANITARY NO. APPLICA�_TIO�.Ns-SUB/isnTALDATE
.11 eapc _� \ —I UNITLtl• C1lOJ ( LOT# LY `- /
OWNERS NAME: •l�/V�'FVV� HONE: CONTRACTOR'S NAME: LIC NO: N/C CO_NT_ROLM Y
uvu y bpi l /� y�
ARCHITECT/ENGINEER: LIC NO: ADDRESS: IA ]Vv� aY� AM)
CONTACD i ^ QT .1111 BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB AgECH
PERMIT ISSUANCE
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
oxz I hereby affirmthat l am licensed underprovisionstAChapter9(commenciagwith
FF)CO Section]000)of Division 3 ofthe Business and Professions Code,and my license is in PANELS
y ❑U full 6rcn and effwY. mrj
FZW License ,la 1.10. 00# OC.i [ UPT02AMPS ✓ri/k'l./�/
m64 Uma Cr rt 11 201-IfIDO AMPS
z0O1nK RCHITECTSFS DECLARATION Ff.ECLARATION OVER 1000 AMPS
oz-m SQ. FLOOR AREA $/SQ.FT.
1 understand my plansshall be used as public norml,
rve cal
� Licensed Professional SIGNS ELECTRICAL �(�• e7 s�//
e,$Y 6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
O T U I hereby affirm that I am exempt from the Connie m'.License Law for Ne - )))
i3 tot followingreason.(Semion]03LS,Business and Professions Code:Anyciry or county TGMP.METEft OR POLP.INST.
f'4 ON J which.squires o permit to c...met,alteq improve,demolish,or repair any nmctme
oa S prior to its issuance,also m the applicant forsuch permit file a signed statement POWER DEVICES
quires pp permi g
CC that he is licensed pursuanuothe provisions of the Contmcmr's License Law(Chapter SWIMMING POOL ELECTRIC
9(commencing with Section]000)of Division 3 ofthe Business and Professions Code) VALUATION
W2, or that he is exempttherefrom and the basis for the alleged exemption.Any violation of OUTLETS SWITCHES-FIXTURES ^ `
GSection]031.5 by any applicant fur n permit subjens the applicant[o a civil penahy of '3✓ n! v v
not more than Ivo hundred dollars($500).
❑ NEW RESIDENTIALF.LECTR _SQ.VU 5 RIES TYPECONSTRUCfION
❑ othe wrk,andeesomat,ofmyemployedorafwed forsalei(sole Business D
ew will dothe,ina,Code:
hpCmisisnot is Liewpse Lo a does at
I. 4,.wria,of
and ertywh ons Code:The Contracmf's License Lew does not apply tort owner of
propertywhobuildsorimproves thereon and whodoes such workbimselfor Wvugh his
If,employees,provided thal such improvements wenotintendnd arofferedforeale. OCC GROUP RES.UNITS
however,the buddingor improvement is sold within one yearofcompletion,the owaer- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,asawner ofthe property,amexdusively, contracting with licensed contractor QTY. PLUMBING PERMIT FEE to FLOOD ZONE APN
amr,lo t the project(Sce.70a4,Business and Professions Coda)This Commands
License l.awdoesnotapply toanownerofproperty whohuilds or improves thereon,and PERMH'ISSUANCE
who contracts forsuch projects with acommotor(s)licensed pursuant to the Contmetols
License Law. ALTER-DRAINffiVENT-WATER(EA) sa FE SU
❑ I am exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE ID
SANITA N
Owner Dam DRAINS-FLOOR.ROOF,AREA.GOND. K
WORKMAN COMPENSATION DECLARATION SCII LT Y N
❑ I hereby affirm that l have a certificate electrical to self-insure,or a rertificale of FIXTURES-PER TRAPRCEI 1'#
Woders'Cnmperratien lnsumnee or ecertified copy therem(Sec.3800,Lab CJ which P KFEE N
covers all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS .CF M#
PolcyN BUliftf DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANA'
❑ Certlfledcopyishmebyfumishod.
FlziF
❑ Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR =< G HE
tiles -OD
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP S SF
COMPENSATION INSURANCE
(This scmlon need not be completed ifthe permit is Income hundred dollars($10D) SEWER-SANITARY-STORM EA.2110FT. F.NERO E v
or less.) - S
1 ertifythat in the performance ofthe work forwhich this permit is issued,l shall WATER HEATER W/VENT/ELECR
not employ any person in any manner so as to become subject tr the Workers - PAID
Compensation Lawsof Cdifomia. Date WATEPSYSTEMITREATING Date Receipt#
z Applicant
Z� 0 NOTICE TO APPLICANT:If,after making this C<mftealeof Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. S •5.5 TOTAL:
E-I CI) become subject to the Wmkerx Compensation provisions ul the Labor Cade,you most
�i , forthwith comply with such provisions or this permit shall he deemed revoked. BUILDING FEE � Ov
' 3g,
W FCONSTRUCTION LENDING AGENCY SEISMIC FEE x•;-Z)
,Z.
1 hereby affirm that there is a construction lending agency for the performance of r3,�,•33
TOTAL: ELECTRIC FEE
O the work for which this permit is issued(Sec.3097,Civ.CJ " 3
Lendeis Name PLUMBING FEF.
D"' F
Lead ex Address QTY. MECHANICAL PERMIT FEE
V I cantly that 1 have read this application and state that the above infarimilim it MECHANICAL FEE
correct. Iagree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE 12J3
.Fy building construction,and hereby authorize representatives ofthis city metner upenthe CONSTRUCTIONTAX
U above-mentioned property far inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costsendexpemeeswhtchmay in any way accrue against soul
AIR HANDLING UNIT(TO 10,0!10 CPM)
in e of the gmn'ngof th' pemtlt.
Z
.
/ yr AIR HANDLING UNIT(OVER 10,IXq CFM)
S nature of Applican Contrac r l/ Date EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT TO 100,000 BTU) Date Receipt#
Will[be applicant or futme building occupant score or handle hazardous material
as defined by the Cupertino Mi ntCpal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code,Section 25532(a)7
El Yes ❑No VENTILATION FAN(SINGLE RESIp)
YISSUAN E
Willtheapplicuniorfuturebuildingoccupantuuequipmentordeviceswhichemit BOILER-COMPOHPOR100,000BTU)
.••hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER.COMP(OVER 100,000 BTU) OCT 1994
Dis11 Yes
r
Yes No NEW RESIDENTIAL MECH.—SQ.FT. /JJ ,
1 have read the hazardous materials requirements under Chapter 6.95 of the r_ Ut ('UT, 1IN(�
California Health&Safety Code,Sections 25505,25533 rind 25534. I understand that
if the building does not currently have a tenant,that It Is my responsibility to notify the
occupant of the requirements which must be met prior in issuance of a Certificate of
Occupancy. J
Owner or auNnrired agent Date TOTAL: S'15ISSUED BY:
OFFICE