26965 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO " -L.crRICAL PERMIT No. r�
BUILDING DI VISION APPLICAT N/PF,RMIT PLUMBING-MECHANICAL. L
IIU[LUING PROJEL9'IDENTIFICATION
6965
BUILDING ADDRESS: SANITARY NO. APPL]CATION SUBMITTAL DATE:
UNIT# LOT QIL�/
OWN17RSN ML': NE: CONTRACTOR'SN LIC NO:
ceg' NIC CONTROL0:0 #
C111'IEC/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: as '> BUILDING PERMIT lNFO
ELECI'RIC.PErRMIT _ FEE
. BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ 'tf ❑ 0
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
nezz Ihereby afflrm that l am licensed underprovisionsol'Chapter9(commencing with TOB DESCRIPTION
ts100 Section 7M)of Division 3 of the Business and Professions Code,and my license is in PANELS
F- fun farce and effect. y� .
pQ„2� License Clava Lie.# UP TO 200 AMPS '`y'],(� h I
va6 Date Conbucmr 201-IOW AMPS ` e v
FyZ ARCHITECTS DECLARATION SQ.FT.FLOOR AREA $/SQ.FT.
Z _ 1 understood my plans shall be used as public records. OVER 1 W0 AMPS
O ns
F: �
SIGNS ELECTRICAL
...41 Licensed Professional
K 6OWNER-BUILDER ATION SPECIAL CIRCUIT/MISC.
d O d V I hereM1y am.that 1 am exempt from.the the CConmecmts License Lew for the
u1�+1s-vFi following reason.(Section 7031.5.Business and professions;Code:Any city or county TEMP.METER OR POLE INST.
CF'u'�; which rtquim a permit m constmct,ulcer,improve,Demolish,m repur any slIDcturc
primes licensed ,nlsorequi the provisions
r vision of the CopermittoLice se Law(torrent POWER DEVICES
yl�ppapter
9(com'hot he ie lncinsedpursunionrt ")of svision the Contractors LicenseLawode)
9or t that
he is ixemith5miomandthe Division Joftheed exeuund.An v iolaCode) SWIMMING POOL ELECTRIC VALUATION
Section
703ISby therefrom and the perbasmit subjeallegedexemlm to Anyviolationof OUTLETS-SWITCHES-FIXTURES
ZQ not roe than
w,a hundred
P$50tmit subjects the applicnnno acivil penalty of
t more than five hundred dollars(SSW).
zz� I,mownemRhe y p y ire R NEW RESIDENTIAL ELECfR _SQ.FT. STORIES TYPECONSTRUCTION
yFCC'� n❑ prouuctunis em to«nwithw forsthei(we.7 m rminm
y... and Pethewod.and lbs he Coeatter's License Law does not apSec.?044,Boniness
end t\nfeniom Cale:The Contmcmr's License Law does not apply to an owner of
prop,uywhobuilds orimproves Neteon,andwhodoes such workhimselfortherugh his OCC.GROUP RES.UNITS
ton employeamen
s,provided that such improvets sm not intended orofferad fersae.If.
however,the building or improvement is sold within oneycm of compleam,the owner-
builder will have the burden of proving that he did not build or improve for purposs of
sale.).
❑-Laxowner oftheproperty,smexclmively contracting with licensed contractorsto QTY: PLUMBING PERMIT FEE MOOD ZONE APN
eamtruct the project(Sec.7044,Business and Professions Cade:)The CrearunMs PERMIT ISSUANCE
tic«se Law d«s not apply tom owner of properly w ho h til ds cr improves therec n.and
whocantructs for such projects with acontmctar(s)licensed pursuant hath,Contractor's
License Law, ALTER-DRAIN&VENT-WATER(G7 FEE SUMMARY
❑ 1 not exempt under Sec. ,B k P C for this reason BACK FLOWVnE R O P -
'n '\R. P 7 ITAR Y N
Owner Dare - t t RECEIPT#
DRAINS-MOOR, F;AREA.CONU.
WORKMAN COMPENSATION DECLARATION _ - COOLTAX Y N
I hembyamrtntht l have ecenificasofecnsentto self-insure.macertificatoof 1 I �I 11�' RECEIPTg
rkn%Comperuatinn lnsumnceon re.ifiedcopy thcrmf(S«.3gW,Iab CJwhich FlXTlJRES-PER P a lJ V KFEE YN
era ell employees under this permit. GAS-EA.SY TEM-1 INCA OUTLETS- RECEIPT#
Palieyp BUILDING DIVISION FEES
Company GAS-FA.SY EM-0V 4(EA) K FEE
❑ Certified copy is hereby famished. -
❑ Cerdlied copy is filed with Ne city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not h,completed ifthe Permit is foroae hundred&Jim(SIW) SEWER-SANITARY-STORM G.200FT. ENERGY FEE
or less.)
I terrify that in the perforns.of she work far which this .I,is tomed,l shall WATER HEATER W/VI?NT/ELECIR
rot employ any .on in any manner so as In become subject he the Worken' PAID
Compensation lsws.f Califierm. Dote WATER SYSTEMIMEATING Date Receipt#
C) 2 Applicant
z NOTICE TO APPLICANT:If,titer making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
^7i become subject to the Workers Compensation provisions of the Labor Code,you must
r
�. forthwith comply with such provisions or this permit shall be domed revoked. BUILDING FEE
GQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
7 z I hereby affirm Nat there is a construction lending agency for the performance ofTOTAL: ELECTRIC FEE Ln 'a
the work for which this permit is issued(Sec.3W).Civ.C.)
L) P Ismdcr's Name
LL Lender's Address QTY: MECHANICAL PERMIT FEE PLUMBING FEE
U I ecoafy that I have read this application and sate that the above informed..is MECHANICAL IEE
7" Da correct.Talmo to comply with Jl city and countym,inunces andsate law,elmiag to PERMIT ISSUANCE
building construction,and hertbymnloriae representotivesof thocity toemctupon the CONSTRUCGONTAX
LJ z
above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agrtt to save,indemnify and keep harmless Ne City of Cu ino ugvnot
liabilities,judgmenu.cosaondexfenvswNchmey inany way. OrIciry AIR HANDLING UNR(TO IO,000 CFM)
ineonwqumc ofthegr tingofthis permit
q ` AIR HANDLING UNIT(OVER I0,000 CFM)
Sig n
ure of Applican4Cantmctor �,/� Date EXHAUSTHOOD(WIDUCTI PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO IW,000 BTU) Date Receipt#
Will the applicant or furore building C occupant erre or handle hHea Health
a material HFBTING UNIT(OVER 100.00s)BTU) TOTAL:
as defincA by the Cupertino Municipal Cada Chapter 9.12,and the Heehh and Safety
Code,Section25532(a)? VENATION PAN(SINGLE.RF.SID) /
CI Y. IJ No TIL
ISSUANCE DATE
Will the upplicamonfutumbuildingo.cupantm,aquipmensordeviecowhichemit BOILER-COVE(3HP OR IW,"BTU)
,Nom air conmminants as defined by the Bay Arca Air Quality Management BOILER-COME(OVER 1W,000 BTU) O
me'?
❑Yea ❑No NEW RESIDENTIAL MECH, SQ,FT.
I have teal the harurdous materials requirements under Chapter 6.95 of the EP 21994
CaliforniaHealth&Safcry Code,Sutions 25505,25573 and 25534. lundersmnd that TI
ifihe building does not currently have a tenant.Nat it is my responsibility to notify the CITY VI' 1aUr LfU ux�
oreapart of the requir meats which must he met prior to issuance of a Certificate of
Ovale,or a
Owner m amhaiud alem Dom TOTAL: ISSUED BY:
OFFICE