26113 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY DE CUPERTINO PLUMBING-MECHANICAL
BUILDING DIVISION PERMIT NO.
APPLICATION/PERMIT 26113
BUILDING PROJECT IDENTIFICATWN
BUILDING ADDRESS: n SANITARY NO. APPLICATION SUBMITTAL D1ATE
p�Q QJAi A— UNIT# LOT# 3.-. $ " C(o
NE NAME: PHONE: p CONT/R/O�CCTOOWS NAME: .a(� + LIC NO: 1
/.} s bo Fes( w {(a•f/^s QI* Id` pg a s 7�"'1 S r N/C CONTROL#
CHITEC /ENGINEER: LIC NO: ADDR SS: E]
u s � in e 4/cs
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT PEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ 0 ❑ K
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Qzz Ihereby affirm that l sat licensed thderprovisionsof Chaptm9(commencing withOU full force0 Section )efO`vis o^3of the Business
ryand fe7 e,and my license is in PANELS
rqyly Licen Class i[ Li mmd& --/Ca• UP T0XXAMP5 'IJ QO
4 do't Date • Contrectrn M 201-IOW AMPS
Z.O y ARCHITECTS DECLARATION OVER IOW AMPS SQ.FT.FLOOR AREA S/SQ.FT.
O2 -1 undersmnd my plans shell be used es public records.
rm�j SIGNS ELECTRICAL
QqSSdd Licensed Professional
od0
5 � u OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.y 1 hereby affirm that 1 am exempt from the Contractors License Law for the
W 3 C y following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE MST.
O-I which reyuires a permit to consmum,alter,improve,demolish,m repair any swcmrt II A 11 1
'Y7 prion.its issuance.k.requires the applicant for such permit to file a signedstatement POWER DEVICES IN
V�Vp
<O that he is licensed pursuant to the provisions ofthe Contractor's License Law(Chapter a p p
o�' 9(commencing with Section 7")of Division 3 oftbe Business and Professions Code) SWIMMPIG POOL ELECTRIC V DATION
a Noe or that he b oxempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES t
Section, - 'y any applicant for apennit subjects the applicant toacivil penalty of x
I more than five hundred dollars(S5W). NEWRISIDENTIALELELTR I S Q.Fr. ES TYPE CONSTRUCTION
m ❑ I,usownerofthepropeay,ormyemployeeswithwagesastheirsolecompensation,
taEL will dotbework,and thestrueturtis not intendedoroffered forsale(Sce.71144,Business
and Professions Cine:The Contractor's License Law does not apply to an owner of
property whobullds.rimpraves therwarand whadoes such workhimselforthroughbis - OCC.GROUP RES.UNITS
own empl oyeee,prov ided Nat s uch improvements are not imended m offered for sale.If.
however,the bu iingor improvement is sold within one yearo(completion,theowner- TOTAL:
builder will have the borden of proving that he did not build or improve for purpose of
sale.).
❑ Las owner.fthepurperly,amexclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
emmurct the proprt(Sec.7040.Business and Professions Code:)The Contractor's PERMIT ISSUANCE
Licenseoe
Law dsnm applytoan.canercuproperty whobuildsorimprovesther ,aq and
whocommets fmsuch projects with acontranor(s)licensed pursuantmthe Contracmr's ALTER-GRAIN&VENT-WATER(RA) FEE SUMMARY
License Law.
❑ I am exempt under Sec. ,B&P C fm this resson BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y—N—
I hereby affirm that l have a certificate ofconsent to self-insum,or a certificate of FIXTURES-PER TRAP RECEIPTp
orkeds'ComJp1Q.enas#a,tsioYn^l�nsurance@omr aWc�enified�/cop thereof(Sec.38W,Lab CJwhich PARK FEE Y N
P.1 cy#I�pOYJ rr ' y ( GAS-EA,.SYSTEM-I INC.4OUTLETS RDIVISION
BUILDING DIVISION FEES
Company am, GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby 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 secdccnneednm becomplated ifthe permit is for one hundreddollars(S1W) SEWER-SANITARY-STORM EA.2010FF. ENERGY FEE
or less.)
I certify that in the performance ofthe work for winch this Permit is issued,I shall WATER HEATER W/VLNT/ELECTR
not employ any person in any manner so as to become subject re the Workers' PAID
Compensation Laws of California. Dam WATER SYSTEMI BEATING Date Receipt#
O z Applicant
z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FIL TOTAL:
tr+ r/i
become subject the Worker's Compensatlon provisions of the Labor Code,you must
t-' forthwith comply with such Provisions or this permit shall be deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herNei ei them iso c.namenti n lena
dinggency for the performance of
U O the work far which this permit is issued(Sec.3097.Civ,CJ TOTAL: ELECTRIC FEE
Lender's Name
;J. P Larders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
0 V 1 certify duet I have mad this application and state that the above information ie MECHANICAL FEE
H"
0. career I agree do comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
E„srn building concoction,and hereby authorize representatives of this city to enter upon the CONSTRUCTION TAX
U 7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. 1
�-1 (We)agree to save,indemnify and keep hamdess the City of Cupertino against
liabilities,judgmems,costs and expenses which may in any way acerae...inainsid City AIR HANDLING UNIT(TO Ill"CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature mApplican/C.ntmcmr Dade EXHAUST HOOD OVIDUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000 BTU) Dare Receipt#
Will the applicant. future icipal Code,Capteng occupant r9em handle Health and material
Safty HEATING UNIT(OVER IW,WB BTU) TOTAL:
as defined by the Cupmino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(0)? VENTILATION PAN(SINGLE RESID)
❑Yes 11 No
ISSUANCE DATE
Will the applicant or future building occupant use equipment ordevices which emit BOILER-COME(3HP OR 100.000 BTU)
fimardlons air contaminants n defined by the Bay Area Air Quality Management BOILER-COME(OVER IWJkq BTU)
PiPAID et?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.Ff. 04
I have mad the hazardous materials requirements under Chapter 6.95 of the MAR — 8 1994
Celifomia Healthti am ni Code,Sections 25505,t it is and responsibility
1 understand that
if the buildi s not rater y have tenant,that it is my responsibility to notify the
.ecmpa of requlreme t te-isauegg_f a Certificate f Q I Lit-
4
h I
on
09iyr or achorrinopagent Date TOTAL: ISSUED BY:
OFFICE