26621 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
A. PERMIT NO.
CITY OF CUPERTINO APPLICATION/PERMIT PLUMBING.MECIIA NICAL 2 6 6 2
BUILDING DIVISION m•„y,,, j;,:BUILDING PROJECT IDENn ••FICAnON„ a.
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA”
- 2Z t0�x1 S LOTH G•11 1
N
I F. NA SISI PHONE CO CfOR'ySNAMe WnNO: NIC CONTROL#
ARCHITEC(ENGINEER: WC NO: ADD S('Cg•//✓/.4/WJE a ` �•J
J / OO Ilei �,�.9 SIJ•
CONTACT: PHONE Q-I:y..Y' .k1...yELE_CTRIC PERMIT+" ( C y .'. ifEE ��,..•,, UE.DING PERMIT INFO i. +„rr
, h
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE 11
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
CSZ Ihimmy affirm that l am licensed anderprovuiwaf Chaprer9(commeaing with
ss100 Satiom 7"1 andefl Division 3 of the Business and Profession;Code.esti my license is in PANELS /r6 /1�
y Wf� full force and effect. ' `/a�rjls�,�
<ZBUj License Class Lic.# UPTO200AMPS
vs
G 2 Dale Conuaclor 201-IOW AMPS
Z_
C ond
ARCHITECTS DECLARATION SQ.FT.FLOOR AREA S/SQ.FT.
O I enund my,lans shell he used as public sands. OVER 10110 AMPS
U
SIGNS ELECTRICAL
6 t J Licensed Profexeionxl
iecl+eclU OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
x5l I hereby Or.But 1 en exempt from dractors e ContLicense Law(or the
to 3 ay following taaton.ISection 7031.5,Business and Pmfessimu Code:Any city or county TEMP.METER OR POLE INST.
l' O< which requires a permit.o construct.der,improve,demolish,or repair any structure to
,yY2 prior to its ismomm.O.regains lhemplicanl fm such permit to file a signed statement POWER DEVICES
W=<0 that he is IicenxA pursuant to de provisions of the Cmma+nr's License Law(Chapter SWIMMING POOL ELECTRIC
a XCLL 9(commencing with Section 7000)of Division 3 ofde Humans and Professions Code) VALUATION
is
w_H or that he is exempt therefrom and the basisforthe alleged exenptim.My violation of OUTLET'S-SWITCHES-FLCIVRES
L•ZY Section 7031.5 by any applicant for a permit subjects the aplirat macivil petultyof
�Z not more than five hundred dollen(3500). NEW RESIDENTIAL E _
LECTR SQ.FT.
CFp n❑ I,uownerofshePropmy,armyemploymwithwagaethe'vmlecmnpetwdm. O TYPE CONSTRUCTIO
willdothework,a theswaumismtimm�moffe fmaale(S .7o .Omisome
and Profession.Code:The Cantrectors License law doe nor apply m an owner of
ownemplw ces,promimp msuchimpmvemmmd naihwmkN off mfh We.hf, .GRpUP RES. NITS
howemployees,p building
or improvement
disown r.
however,the building mden of proving
is hath a did armyee or imponNon,the owner. TOTAL:
builder will have the burden of proving thv.he did ret build or improve for purpose of
--nnw✓sr v,.c..--.
ore). `t11 3 ;3:PLUMBING PERMITy, .,y�� "a:'FEE�jac FLOGDZON APN
❑ I.uownerof the pmpeny,amexclusivelycontnctin6 with licensed contractors to {. �:.�_.,., 4.s>nr,sv:�s.vw.v'erc`:.•tvv rPs"s.•+'s..'..z.
instruct the project(Ser.7016.Business and Professions Code:)The Contramts PpRIBpp ISSUANCE
Lic,n.e Lawdoes notapplytowownerofpropmywhoboildsorimpmvntherton.and aawa
whocmnmecks for such projects wiNamnvacrmfs)licensed pursuant tithe Consraemrs ALTER-DRAIN&VENT-WATER(EA) 'Pa'"``•-`o"-" 'r_-.,,- 'i�:
License Law. tiky+i.�;`eia'aFEE SUMMARY 4,,f,��•'- .r
❑ I em exempt under Sa. .B&P C for Nis remon BACK FLOW PROTECT.DEVICE ,.
SANITARY YN_
Owner Dau RECEIPTN
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR.ROOF.AREA.GOND. SCHOOL TAX YN_
❑ I hereby mffum that l have a certificates ofomenl to elf.inert,me cmibcareaf FlXTURFS-PAR TRAP RECEI1`T#
Worken'Compensetionlnsunaeoracenificdcopytheaof(Sa.380GLab CJ which PARK FEE YN_
RECEIPTN
coven all employee's under this permit. GAS.EA.SYSTEM.1 INC.4 OUTLETS -
BUILDING# BUILDG DIVISION FEES
Company GAS.F.A.SYSTEM-0VER 4(EA) PLANCHECK FEE
❑ Certifiedcopyisherebyfumished.
❑ Cmifiall copy I,filo with the city inspection division. GREASFJWDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Bussenction need not be,completed ifthe Permit is forms,hundred dollars(5100) SEWER-SANITARY-STORM EA.20UFT. ENERGY FEE
or less.)
I certify that in the perfomunttof the work for which this Permit is issued.I shall WATER HEATER WNFM/ELECTR
not Play any person in any rammer ser a.bressims,suhucy P the Workers' PAID
mpeaation rCagbrwja� du "If -+TY WATER SYSTEM/TREATING Date Racip#
O z Applic nt 6 [ l
NOTICE TO APPLICANT:EL afar making this Certificate of Exemption.you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
F rA become subject a mpm
the Workers Cosauon provisions of the Lobar Code.you mon
Ce > faMwith comply with such provisions or this permit shall he deaned maked. BUILDING FEE
1 [] CONSTRUCTION LENDING AGENCYSEISMIC FEE
Z) z E hereby,affum that then is a construction lending agency,for the performance of s/"' ELECTRIC FEE
V O the work for which the permit is issued(Sec.3097.Civ.C.)
Landers Name xc F'.v raeLn.sgnu'm'fa[w'swsaa' R`F';, se
fI. PLUMBING FEE
F L nd<r'h AJdreva . p 'MECHAMCAI PERMIT �fJ �y FEE
N/ I certify the 1 have read this applicmion and eau Ino the above information is - 'v '^` 's'a""'+,aec;rmeasTx.ec+n+, :4Ib�515 8y"," ...—.Ats,:
MECHANICAL FEE
correct.l agree to comply with al city and county ordinances nod auk lows relating to PERMIT ISSUANCE
F' y buildingconstmction,and hereby authorise n ntativeofthscity to mar upon the CONSTRULTIONTAX
(„) Z above-mentioned property,for inspection purposes. ALTER OR ADD TO MECH.
(We)agree m save,indemnify and kap harmless de City of Cupertino again..
Oabiliors,judgments.costs andexpensas whichmay,in anywayvnrue agvinst said CityAIR HANDLING UNIT(TO III"CFM)
I.cost ce of the granting of this permit.
177 AIR HANDLING UNIT(OVER 10.000 CFM) a
1
snare of App em
noConncsor Dau EXHAUST HOOD(W/DUC17
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO HOWBTU) Data Receipt N
Will the applicant or future building Occup ore store or handle hazardous mmmal T
as defined by the Cupertino Municipal Cork,Chapter 9.12.and the Health and Safe,, HEATING UNIT(OVER IM."BTU)
Cork,Section 25532(x)? VENTILATION FAN(SINGLE RESTD)
❑Ya ❑No
ISSUANCE DATE
• Willthenpplicanmrfu..re buildingoompant use,equipmcnmrdevica whichemit BOILER-COMP(3HP OR 10ROW BTU) \\
hamdons air contaminants as defmW by the Bay Arae Air Quality Manogemem BOIL ER-COMP(OVER ROOM BTU)
Dinricf! i
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ,FT.
1 have read the havmkus mmerials equimmnu under Chapter,6.95 of the .3I� �j 1 1 04
Califomiu Health&Safety Codon Sections 25505,25533 and died �•1 25534. 1 understood died
If the building does not currently have a tenant.that it is my rcspmsibility to notify the
Acopam of the requirca mems which muss he mprior to issuance of a Certificate of I'�`y t,r 4 V T[,{?1114k
Occupancy. 1
Owner or amhonzed egem Date TOTAL: ISSUED BY:
OFFICE