26146 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUIL UIN -ELECTRICAL PERMIT NO,
APPLICATION/PERMIT PLUMBING-MECHANICAL 26146
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: ' SANITARY NO. APPLICATIONSUNMITTALDATE
•O '�' `— ^ — _ UNITN LOT#R' N
OW A C A NO: N/C CONTROL—p`
AI
ARCHITECI'/9N INFER: �j•,�LIC NO: ADDRESS: ^ 1:1QTY, ELECTRIC PERMIT
CONTACT: PHONE: G•f+ FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE / CY�/`" - ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL )OBDESCR,;
mwz Iherebyaffinn that lam licensed underprovisions ofairptef9(commencing with
I1100 Semion]000)of Division3 oRhe Business and Prafessione Cade,end mylicenee is in PANELS
KU full force and effeol. )''�II !
ce, Diten Lic.# UP T0200 AMPS
m'y Dae Contractor 201.1000 AMPS
F
'cot
ARCHITECTS DECLARATION SQ.FT.FLOOR AREA $/SQ.FT.
OZ Jp I understand my plans shall be used as public recards. OVER 1000 AMPS 11- 1...
r-�6 SIGNS ELECTRICAL err O /..
5555y Licensed Professional
X N OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
Oyu I hereby affirm ilia,I ma exempt from the Connector's License Low far the ,1 I
W'3Oy¢ following reason.(Section]031.5,Business and Professions Code:Any city or county TEMP.METERORPOLEINST. V
1--'�01 which requires a permit to container,alter,improve,demolish,or repair eery snucwre
prior t0 its issuance,also requires the applicant fortieth Permit to file aligned sta¢meat POWER DEVICES DATE
W00 thmheislicensedpursaan,1.he provisions ofthe Contractors License Low,(Chapter _
d 9(commencin 'N Section of Division 3 of the Business and Professions Cade SWIMMING POOL ELECTIU —or that he ----
o (commencing ) VALUATIO4—
W❑y Section731.5haexempt nysp remand the permit subjects medexsmption.Any violation of OUTLETS-SWITCHES-FIXTURES �Q .M/�
C notmore than by nnyve dreddo][ ($50rmit subjects[be applicant[oecivil penalty of C/ 'L7(J6
C mnot more rofthedre ny.ormye 0). NEWRFSIDENTIALELECTR _SQ.FT. STORIES TYPECONSTRUCfION
❑ Lasowrk,anhepropeny,ormyemployeee offeregwasahe(See.TIM,Business y will dothewons andmehe Contractors
License
o w does not apply on so Business
and Professions Cada:The ves tmemh rid who Lew does not apply lf an owner of
fs
.. propenywhoot,provided
suchimpravndwho does manors trade oroff refthroughhie OCC.GROUP RES.UNITS
ownemployees,provided Thrsuchimprovld wit in ne imendedmoffered forsalnIf,
however,thehave
buimpmpsovinishat he iinaneyear of improve Torpthe owe r.
of O
builder will have the burden of proving that he did not build or improve far purpose of
❑ I,as owner ftheproperty,aro exclusively contracting with licensedcontmnors[o QTY' PLUMBING PERMIT FEE PLOOD ZONE APN
construct the project(Sec.704L Business and Professions Code:)The Contractor's
License Law does antapplym wrommerofpropeny whobuildsorimmostathereon,and PERMIT ISSUANCE
who contractsforsuch projects with acomraaor(s)licensed pursusntto[he Commcmra ALTER FEE SUMMARY
License Law. (BA)
❑ 1 am exempt under Sec. ,B&P C for Nis reason BACK FLOW PROTECT.DEVICE SIDE FEES
SANITARY Y N
Owner Date ATRECEIPT#
/ WORKMAN COMPENSION DECLARATION DRAINS-FLOOR,ROOF,AREA,GOND. SCHOOLTAX Y N
• H IherebY affirm that lhave ncenificam of consent to self-insure,oracenificem of FIXTURES-PER TRAP RECEIPT#
Workers'Compensation Insurance or acenified copy thereof(Sar.3900,Lab C.)which PARK FEE Y N
covers all em ?yea's un er thisrrryy1le RECEIPT#
Policy# l 1'�1 RI— �� GAS-EA.SYSTEM-1 INC.4 OUTLETS BUILDING DIVISION FEES
Company—rd�+ r/' rad. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cvdt sd copy is hereby with
the
city
CeniFied copy is filed with the city inspection division. Ll
GREASKIRDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need native completed Hilo,permit is foronehundred dollars($100) SEWER-SANITARY-STORM EA.20MT. ENERGY FEE
or less.)
I certify that in the performance of Ne work far which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to become subject to the Workers PAID
Compensation Laws of Califomia. Date WATER SYSTENVTRGTfNG
Z
Applicant Date Receipt#
O
NOTICE TO APPLICANT:If,after making[his Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.ET. TOTAL:
N became subject o the Workers Compensation provisions of the Labor Code,you must
�. 7 forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
aq CONSTRUCTION LENDING AGENCY SEISMIC FEE
U z I hereby affirm that there is is consnumion lending agency for the perfafmance of
ELECTRIC FEE �•
Q I
the walk which this pe.,is issued(Ser.3197,Co.C.)
CT. r� Lenders Name
U Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
�
1 certify that 1 have read this application and se that the above information is MECHANICAL FEE" A. tor
correct. Iagree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
F-' building construction,and hereby amhonaerepresiditiives ofthis city to enterup Tithe
U 4 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
G (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way seems againslsaid City AIR HANDLING UNIT(TO 10,000 CFM)
in cansequjp a of he granting of this permit.
/ 1 - �..-.a ^/ AIR HANDLING UNIT(OVER 10.000 CPM)
Signor pphcnT/Con ret at
Date !— EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Wil l the applicant or future building ormpant shore or handle lmrsrdo°s material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Cupertino Municipal Cade,Chapter 9.12,and The Health and Safety
Code,Becton 25532(n)]
❑Yes 11 No VENTILATION FAN(SINGLE RESID)
Will the uconta manus a,building occupantay Amu
Air Quality Management
District?
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
. hazardous air contaminants as Defined by the Bay Area Air Quality Management
District? BOILER-COME(OVER 100,000 BTU)
13 Yes El No NEW RESIDENTIAL MECH. SQ.FT. wa. p H p�
I have read the hazardous materials reqS requirements under Chapter 6.95 of the I Y
Califomia Heald,&Safety Code,Sections 25505,25533 cod 25534. I understand that
ifthe building does not currently have a tenant,that it is my responsibility to notify the
account of the m2amones which must be met Inner to issuance of a Certificate of
Occupancy. _ ' -94f 1
Owner or antho' agent pate TOTAL: ISSUED B
OFFICE -