26379 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPF, NO n PERMn'No. 26379
BUILDING DIVISIOSIO APPLICATION/PERMIT PLUMBINGN .MECHANICAL
BUILDING PROJECT']DENT ItTCA'TION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
O V Td✓�s+v
UNIT or LOT
WNERSNME PHONE:PHONE: C NTR9(T R'S N'E: I' LICN II VV
1 ` IC /Y NIC CONTROL#
A 'fJ:Cf/;IINNEt',� LIC NO: A SSS N ❑
CONTA,/�s�/:�K�*�L•.a✓✓�- x PHO Y' _
{' BUILDING PERMIT INFO
QTrY w14Y ELECTRICPERMIT FEE
BLDG ELECT PLUMB MECH
PE MISSUANCE "�A ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL Y
Metz I herehyaffrmi that l am ticenudunderprovisionsofCbsepter9(commencing with TOB DESCRIPTION
Y100 Section]000)of Divlx�Licsi«ess and Prom�t�Coads,and my license is in UP 0200 AMPS
ttet--ZF fullLicense
force nse Clad cff S
,Fzm License Clas u
w D y D.e Convenor / 201-IOW AMPS 5 FT.FLOOR AREA S/SQ.PT.
z f—. ARCHITECTSD C RATION OVER 1000 AMPS Q
CZ-0 I undersmad my plans amil be used as public remrda.
r4 W
� Licemcd l om,siunal SIGNS ELECTRICAL
etQ OWNER-BUILDER DECLARATION SPECIAL CI QCIT/MISC
OLF 1 h<mby e1Dnn rhes 1 am exempt from the ContecmYa License Law,for the
LLOm lullowing reason.(Section703 7031.5.Business and Ro(essione Code:Any city county TEMP.METE OR LE /eta
w which requim a permit to construct,eller,improve,demolish,or repair any mumm,
Y� printo its issuance,also reyuGed Ne applicant for such pemtiuo file a signed etatemem POWERDEVICES 1 t
Tet G p that he is licensed pursumno the provisions of the Convector's License Lew(Chapter
tu' e� 9(commencing with Section 7M0)of Division 3 ofthe Buainessand Professiom Code) SWIMMING LELECOUC VALUATION
ad M,, ormatM is exempt therefrom and the hems for the alleged exemption.Any.........of OUTLETS S CHES \ ress �OD
Stenione than my dyed&[[.a
fore permit euhjens the upplicwt to a civil penalty of
g not me than fivethcpmpdollarsyemp. coup NEW RESIDENTIALELECTR _SQ.FT.
❑ othe wrk,mads properlymisnotmpinyeeawithwagaasthei(Sm.7ompewness STORIES TYPE CONSt32UCT10N
d will dathe,imis Corms he ConiecornLnense Law does
aide orrfSec.]ohe Business
and Profesons Cade:The Cer .donsars License Law des not apply to an owner of
own employe provirimprovn memenendwho ts scaaucllmonktende Mmaelfncthroughhia OCC.GROUP EUNITShowempl.yeailding edthatsuch impis sold :thin ne:men foornpffereAthese.R,howevep theave'e brrenof pmeatissoldedid abuild ofimprovtioatheewna TOTAL:
huildn will have m<burden of proving that he didnt build m improve forpurpose of
sole.).❑ I,mownerufthepmpeny,amexclusivelycmuwtingwiNlicensedconwctorsro QTY. PLUMBING PERMIT ME FLOOD ZONE
conswc.the project(Ser.7044,Business add Professions Cad)The Cmdrectar'e PERMIT ISSUANCE
License Law does nm apply man owner of property who bui Ids or improvesthereon,sand
who contracts forsuch projcets with acontmemr(s)licensed pursuant to the Contractor's
License Low. ALTER-DRAIN&VENT-WATER(FA) FEE SUMMARY
❑ 1 nn exempt under Sec. ,B&P C fur this reoson BACK FLOW PROTECT.DEVICE S E
SANITARY Y N
Owner Data RECEIPT p
WORKMAN COMPENSATIONDECLARATION DRAINS-FLOOR,ROOF,AREA,GOND, SCHOOL TAX Y N
❑ Thereby affirm thetlhnveecmificmmof ofconconsent to self-ec.38..LabCficate of RP.CEIPTp
_ FIXTURES-PER TRAP
covers all employee's 1 lnsuren<�te Jtl ed, f(Sm.3gW.Lab CJ which - PARK FEI3 RECEIPT or
N
Palle _ (7zZ GAS-EA.SYSTEM-I INC.40UTLETg BUILDING DIVI O S
C P GAS-EA.SYSTEM-OVER 4(EA) PIANCHECK FEE
ertifid co is hereby(um�d.
Certified copy is filed with the city inspection division. GREASRANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OP EXEMPTION FROM WORKERS' GREASETRAP SOILS FCR
COMPENSATION INSURANCE
(This section need notbe completed ifthe permit is Intense hundred dollen(SIM) SEWER-SANITARY-STORM EA.20017T. ENERGY FEE
or less)
Icertify that in the performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELGCTR
not employ any person in any manner so as to become subject to the Workers' PAID
.z Compensation Lawsof Califomu. Date WATER SYSTEMJTREATING Date Receipt to
Applicant
O NOTTCETO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL MOB. SQ.FT. TOTAL:
V) become arbiter to the Workers Campenutim Provisions ofthe labor Cade,you must _a
fonhwith comply with such provisions or this Permit she]be deemed evoked. BUILDING FEE
Q. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
U z 1 hereby off that them is issued
(Sm.
leading97, isagency for the perfncmance of
O the work for which this permit is teased(Sm.309],Civ.CJ TOTAL: ELECTRIC FEE
Lender's Ndme _
U' F' Isndde Address QTY. '^ MECHANICAL PERMIT FEE PLUMBING FEF:
O U I certify that I have read this oppliwoon end state that the above information is
�w IJ-I mmato r .Iagree comply with all city and county ordinances,and nate owe adding to PERMIT ISSUANCE MECHANICAL FEE
F building construction,add hereby euthorire«presmutivn allies city mmhoupon Me CONSTRUCTION TAX
V .boor-menti.oal property for inspection mrpom. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless me City of Cupertino against
liabilities,judgments,costs and expenses which may in my way accrue silence,aid City AIR HANDLING UNIT(TO I LOW CFM)
in consequence of the grouting of this pencil.
AIR HANDLING UNIT(OVER 10,001 CFM)
Signature of AppRernt/Cmdremr Dote EXHAUST HOOD(W/DUCO
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I00,000 BTU) Dom Receipt#
Will the aupticans or future building occupant since or handle hnallous material HEATING UNIT(OVER IW,000 BTU) TOTAL:
a defind by the Capenino Mu Mel Code,Chapter 9.12,and the Health and Safety
Cade,Section 255320 VENTILATION FAN(SINGLE RFSID)
❑Yes No
ISSUANCE DATE
Will he epplicanmrfuturchui ingoccupantuseequipmemordeviceswhich emir BOILBR-COMP(JHP OR IW,WU BTU)
hazardous air mention ss fined by me Bay Am Air Quality Management BOILER-COMP(OVER 100,000 BTU) QQ�� p 1f�
District? P pet D
❑Yea No NEW RESIDENTIAL MECH. SQ.FT. py
1 have read the hamodous materials reqummems under Chapter 6.95 of the �JIV 1 ,r
I lenith&Safe C 5505,29533 25534.1 understand mat //''��t 1!' ,4
if the building n0Y a ant.mat it is dpomibility to notify me
occupant of me reqs' ca be met pre issuance of a Ce 'fiche rd CI t r
OccupIf
ancy. S ` � EHIIIVU
-0 44d e TOTAL: ISSUED BY:
OFFICE