26525 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDArE-ELEC RTCAI, - PERMIT NO. 26525
� r/� r
APPLICATION/PERMIT PLUMBING-MECHANICAL. / 5-/ 5
BUILDING DIVISION BUILDING PROJECT IDENTIFICATLION - 5 L V
BUILDING ADDRESS: - yA ` SANITARY NO. APPLICATION SUBMIT]At.DATE
/D I t,J /�/ • r ^" ' " ' �• • UNIT# LOTis
OWNERS NA E: PHONE: CONTRACTOR'S NAM,Ey� LIC NO:
N/C CONL190LW
l L
LeO�v i •/AC//�/ / G '
•ARCHITELT/ENG�IN�EER�:I LIC NO' ADDR4 D V J Gi�l e ❑
corvl'acr: PHONE: - BUILDING PERMIT=INFO -
QTY, ELECTRIC PERMIT FEE -
166 `�� PERMIT ISSUANCE 11 ELECT PLUMB MECH
J�
LICENSED CONTRACTOR'SDECLARATION APPLIANCES-RESIDENTIAL
JOB DESCRIPTION
El
X02 lhembyuff Divisithaton
I amlice Bitaimed dupmvislooscam.Code,an omy Lomas
,1 W t fall fares tim of Division 3 oCf 0e Business and Profeesiona Code, d y license is in PANELS
FFa�F full fumeand affect 1 LaeN ! l '23Qy UP TO 200 AMPS
F WUIy License lass lam- 1 t0 i� J -
6 at,W Dae Contmcmr LE iRa/= 201-1000 AMPS
Z hO ARCHITECT'S DECLARATION OVER If100 AMPS SQ.PT.FLOOR ARA $/SQ.FT.
O Z 1z I understand my plans shall be used as public records.
K641 Tal SIGNS ELECTRICAL
a4 Licensed Professional
a W UOWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
I hereby affirm that I am exempt from[be Conlmclore License Law for the I' ` J u
1+13 a y following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE MST. � _
(_ which requires a permit to consumer,one,,improve,demolish,or repair any weremre p�I �I
�rWY� prim to its issuance,also requires the applicant mrsuch permit to file a signed statement POWERDEVICES / \V,� F sx..v u 1.1
oe WW<0 Lha he is licensed pursuanl to the Provisions of the Contractor's Licence Law(Chapter
oxo} 9orma 7031.5 by
with Section 9000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC - , ION
a 9 that h enm
NIS t
W^,y .5 by anxempt ty+pifthe permitsujthe asege aWlica exemption, civiny l
of
Fa .Sh liwntfsra til subjects the�pplicantmacivil penalty of OUThETS-SWITCHES-FIXTURE 77—---7_
__--
ran moretban five hundred
ny,dollars
myem). NEW RESIDENUALELECIR _SQ.FL - STORIES TYPECONSTRUCI'ION
43m ❑ Lasowrk,anthestrery,ormyemployeeswilhwed forthei(See.compensation,
will do@ework,and the he cture Comisnotint nded kende Law ed,net e
„Iy 144,Business
and my wisinnv Cmde:The Contractor's License Law does not apply lf an owner of
own erty wyees,provided
dsorimproves hat such improand who dues such workhmdedtiroselfor tbroughhls -
empleyees,p Ing or(fiat snement is
whin not year cdeomplitered'heo e.If,r- OCC.GROUP - RES.UNI'I'S
huwevee the tIhave the burden
of pre,
that
lie id none yea orimproe for puTsweef '
builder will have the burden of that be did not build or int for TOTAL:
proving prove purpose of
-
❑ I,as owncroflhc pro,erty.amexdusivelycnn0azting with license,convectorsto QTY. ''PLUMBING PERMIT FEE - FLOOD ZONE APN
construct the project(See.9044,Business and Professions Code:)The Contmetm's ,
whonse LawN for mol applymawith acofprrperty licensed
pumimpro thethereon,and PERMIT ISSUANCE
wboreLow.finsuch projects wilhawnvaetorts)licenend pursuanuo the Contrdcmr's ALTER-DRAIN&VENT-WATCH(EA). - - -FEE SUMMARY
Lice se Law. '
❑nl am exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Data RECEIPT If
• DRAINS-FLOOR,ROOF,AREA.GOND.
WORKMAN COMPENSATION DE CLARATION SCHOOL TAX Y N
❑ Ihercby affirm that have ecertifwte hemostat orecertificate of FIXTURES-PER TRAP RECEIPT'#
Workers'Compensanon lnwmnwoor�racearifiedcoppy thereof(Sec.3g00,LebC)which PARK FEF. YN
cover,all employee's tyt l / l?q % GAS-EA.SYSTEM-I INC.40lIThF.TS RECEIPT#
Policy# 5 BUILDING DIVISION FEES
ompartyhereGAS-EA.SYSTEMOVER4(EA) PLANCHECK FEE
oy
Certified cix hy famished.
❑ 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 need not be completed Unit,permit is for one hundred dollars($IIXR SEWER-SANITARY-STORM EA.200T. ENERGY FEE
ales,),
I certify that in'he performarseofthe work for which this permit is issued,l shall WATER HFATER W/VEIsT/ELECI'R
nal employ any person in any m as to become subject to the Workers' PAID
Compensation Laws of California. Date eo WATER SYSTEM/I'REATING Dale Receipt#
0 C NOTICE TO APPLICANT:If,after makingthis Certificate of Exem C T TAL:
p ton,you should NEW RESIDENTIAL PLEB. SQ.FT.
Applicant
FH becomesubicet to the Worker's Compensation powisionsofthe Labor Code,you must
a , forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
Q7-. CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the performance of TOTAL: ELECTRIC FEE
U O the work for which this permit is issued(Sec.3097,Civ.CJ
41s p Lender's NamePLUMBING FEF.
0 U
Lender's Address QTY, MECHANICAL PERMIT FEF.
1 certify that 1 have read this u,plic ticn and state that the above information is
�” a caredlagree to comply with all city and county ordinances and date].a.la[ing lm PERMIT ISSUANCE. MECHANICAL FEE
V(•' building construction,and hereby auWoria repmsentatisceofthis city to enter upon the CONSTRUCTION TAX
above-mentioned pro ray for inspection purposes. ALTER OR ADD TO MECH.
(Wo)ogrelgmz
d keep less tits ily of Cuperino against
liabilities,ju m whi ay in any azcticra,nstsaldCity AIR HANDLING UNIT(TO 10,000 CFM)Inns nc et -
AIR HANDLING UNIT(OVER 10,000 CFM)
14
SI reo ,plica Contra Date EXHAUST HOOD(W/DUCT)
PAID
IIA' DOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dae Receip[N
Will the applicant or future buildingoecupant smreoThandle hazardous material HEATING UNIT(OVER 100,0011 BTU)
as defined by IM1e Cupertino Municipal Code,Chapter 9.12,end the Health and Safety
Code.Sedi O 893$ a)P 0NVENTILATION FAN(SING LE RE.SID) a
,000 BTU) 'y ISSUANCE ATE
Will theapplicantnr futurebuildinges upanl useequlphemordevices whlchemiBOILER-COMP(3HP OR 100,000 P A A h
hazardous air conmmmares as defined by the Buy Area Air Quality Management
District'! BOILER-COMP(OVER 100,000 RTU) it
n
11 Yet; [IN. - NEW RESIDENTIAL.MECH. SQ.IcU SB/� /(j ��
I have read the hazardous materials requirements under Chapter 6.95 of the `I r 7� ro t7 ��
California Health&Sufety Cmle,Sections 25505,25533 and 25534.T understand that / �
if the building does not currently have a tenant,that it is my aw,sto lehly to notify IM1e \,/h �V(✓�
cultist of the requirements which must be met prior an Issuance of a Ccatificme of fI✓Jj�V
Occupancy.
Owner or authorized agent Dam TOTAL: ISSUED BY:
OFFICE