26977 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUD: —FLECTRWAL PERMIT NO.
APPLICATION/PERMIT PLUMDRTfBING-MECHANICAL ^/N
BUILDING DIVISION
BUILDING
PRO.IKC'i'IDENTIFICATION c Vh 977
BUILDING ADDRESS: SANI'1'ARYNO. APPLICATION SUBMITTAL DATE
m U A Cou4i5C UNIT# LOTH Qom `J
7
it
K AMFPHONE: C ACTOR'S NAME: LIC NO: N/C CONIROLp
AR_ memA Kam
HITECDENGINFER: LIC NO: ISS$ ❑
CONTACT: PHONE: e, r
QTYELE&W BUILDING PHRMI9'INTO
PERMIT ISSUANCE
BLDG ELECT PLUMB MUCH
1 ❑ O ❑
CONTRACI OR's DECLARATION APPLIANCES-RESIDENTIAL L*
OCZ Ihereby e of
3 ofth BusinlsrprOWsionsofOaprer andicyencrratish — LOB DESCRIPTION
gstion]IXg7 of Division3ofthe Buainesappand P�rofess^io�ns'C1ode and my liceveis in PANELS
fZV iccnu Clms _Lis.#.,{ A"{ UP TO 200 AMPS
m=y Dae Concrete, 201-1000AMPs
1—.isZ ARCHITECTS DECLARATION SQ.IT.FLOOR AREA $/SQ.PT,
OZ-0 J I understand my plea shall be used u public recoNa OVER IOW AMPS
K��QSIGNS ELECTRICAL
licensed 1'ndcsuonal
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
�oy�(J,OaU I hereby affirm that I em exempt from the Camruclors License Law for the
ul'+Ia.,Fir following rernna(Section 7031.5,Business olid Professions Code:Any citymenanty TRMP.METER ORIOLE INST.
which raptirm It permit 10 emillo et,nine',improve,demolish,or repair any srtuaure
Nab prior to its issuance,also requires the applicant for such pimnitto file a signed statement POWER DEVICES
0. Oc that he is licensed pursuant in the Provisions of the Contractor's License Lew(Chapter
aX�li 9(eemmeneing with Section 7000)of Division 3ofthe Business and Profeasiona Code) SWIMMING POOL ELECTRIC VALUATION
yl_y or that he is exempt and the basis for the alleged exemption.Any violation of
(_ZQ Section 7031.5 by any applicant for a Permit subjects the applicant is a civil Panity of OUTLEfS-SWITCHES-FIXTURES
9 paid more than fire hundred dollars(1500).
�� ❑ I,asownanOhepmo ny,ormyemployeeswithwagesmtheirsolecompemadon, NEW RESIDENTIAL ELECfR _SQ.FT, STORIES TYPE CONSTRUCTION
C3— will do the work,and the structure is not intendedoro(feted fo1s8c(Sm.]041,Business
and Professions Cade:The Contractors License Law Jens not apply in an owner of
propcnywbobi ildsorimproves thertomand whoduca such work himselforthroughhus
own cmployces,provided that suchimpmvemems ell not intendedoroflbredfrrsale.If, OCC.GROUP RES.UNITS
however,the buildingor improvement is sold within one year of completion,sheowner-
builder will have the buNen of proving that Int did out huild or improve far pmpose of TOTAL:
suit.).
❑ Ins ownanl mepmpeny,am endusmvalywmrun'lig wuh hcansedeontneton to QTY. PLUMBING PERMITPEF ;, Ia,00D'LONE ApN
construct the project(Sec.7094,Business and Profusions CndeJ The Contactor', "s
License Lawdoes notapplyman ownerofprnpeny who builds orimpmvestherton,end PERMIT ISSUANCE
who contracts forsuch projects witha contracim s)licensed pursuantto Ne Cormuchn''s
Lioenss Law. ALTER-DRAIN&VENT-WATER(EA) PEE SUMMARY
❑ I am exempt under Sec. ,B&P C for thi son E SUM FE
AC FL R CT.DEVICE SANITARY YN_
Owner Da¢
WORKMAN COMPENSATION DECLARATION V DIUINS-PI:00i, F. GNU. RECEIPT
• c _ f�a SCHOOLTAX Y N
❑ Ihemhy effinmthmlhaveettnifcne of conunnn self-insure,orate fieateof t.F1X V � P R P'. g a RECEIPT#
Worken'Compensationde,thus .i,. fi<Jenpy thercof(See.3g00,Lab hich� - PARK FEC Y__ry
ars ell employee's under this permit. GAS- 1 UTLHTS RECEIPTk
Policy tl
company BUILDING DIVISION FEES
❑ Cumficdcopylsh.byfundshed. PLANCHI3CK FEE
❑ Certified copy is Bled with thecity inspection division. GREASIp1NDUSTRL WAS FE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
INSURANCE
(This acminn need not be completed ifthc permit is forenehwdred dollen(5100) SEWER-SANITARY-STORM IIA.20#)19'. ENERGY FEE
or less.)
I certify that in the Performance ofNewark for which this permit is issued,l she] WATER HEATER W/VENIUCLECTR
not employ any person in any mamma so as to become subject to the Workers
CPAID
z ant WATER SYS /I
ompensation lswa of Celifomia Date TEMREATING Date Receipt#
omps
O0 NOTICE TO APPLICANT.If.ada making this Cenificak MExemption,you should NEWRESIDENTIALPLMB. SQ.ET.
IA become subject the Wntkers Compensation provisions ofthe Labor Code,you must TOTAL:
a
forthwith canply with such provisions or this permit shall shall he deemed revoked.s ski BUILDING FEE
A CONSTRUCTION LENDING AGENCY SEISMIC HE
z I hereby affirm that them is a construction lending agency for the performance of
U O the work for which this permit is issued(Sec 3097,Civ,C.) TOTAL: ELECTRIC FEE
Lts Lender's Name
0 U Lenders Address QT'Y. MECHANICAL PERMIT' THE• ,= PLUMBING FEE
1 eenify that I have read this application and state that the above information is
correct.I agree to comply with all city and county endurances and sate laws relatin to MECHANICAL M
F' Cn building construction,and hereby authorize reprcsentadvm ofthis city menter upon PERMIT ISSUANCE
U Z above-mentioned progeny for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION'TAX
(We)agree to save,indemnify and keep hamtlexs the City of CupaMo against
liabilities,judgments,costs and expenses which may in any way accrue age' staaid City AIR HANDLING UNIT Biber CFM)
co
prince of th renting ofYmi. t. ZI
YAIRHANDLINGU14IT(OVER 10—CFM)
'igm rco ApPlic nt/ mtmna11 D e EXHAUST HOOD(W/DUCT)
PAID
I IAZARDOUSMATF.RIALSDISCLOSURI? I IHAI'INC,UNIT(TO 100,000 BTU) Datc Receipt#
Will the applicant or future building occupant since or handle for ardous material
u defined by the Cupertino Municipal Code.Chapter 9.12,and the l lealth and Safety I IPATING UNIT(OVER 100,000 BTIO R #TOT
Cotte,Seeded 25532(a)9
❑Yes 0 N VENTILATION FAN(SINGLE RES][))
BOILER-COMP(3HP OR bat'"BTU) SUA�E DATE
Will theapplicwtorfumrebuildingcecupanl uxeyuipmemnrdevices whichcmit19g
haealloua air contaminants u defined by the Bay A.Air Queiiy Management B
OILER
/s VV
District? trll r ser• e
❑Yes ❑No 1 have read the hrl-rJous mkrialsrequirements under Chapter 6.95 oftheCalifornia Health&Safety Code,Sections 25505,25533 and 25539. I understand that
if the building Jou not curre"Fou of the requirements which must be met prior to Issuance of o Ceniflcak of
fkcupency.Owner orawsmxz agent DmISSUP.0 HY:
OFFICE