26053 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES-USE BALL POINT PEN ONLY
CITY OE CUPEPLUMBIN -MECHANICAL PERMII'NO. �� O
BUILDING DIVISION
BION APPLICATION/PERMIT
BUILDING
BUILDING PROJECT IDENTIFICATION
53
BUILDING ADDRESS: SANITARY NO. APT
�PLICAI�ON SUBMITTALTE
� DA
DD
V 26-0 UVVN/✓e y / • UNIT# LOT
OWNERS NAME: /`/ / PH* E:CONTR6Cfpg'S NAMLIC NO:
.`/J gIV1 N/C CONTROL#
ARCH[rECT/ENGINEER: LIC NO:' ADDRE 5 ElCONTACT: PHONE: �f�'7
QTY-1 ELECTRIC PERMIT PER BUILDING PERMIT INFO
vBLDC ELECT' PLUMB MECH
PERMIT ISSUANCE =K 11 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
C o4z I herebyaffirm that l amlimraudunderprovisionsafChapter9(commencing with mss' JOB DpacfZCIRHON
FOQ Section W full force e00ideHmtvosion 3 of the Business and Pmfeasiona Code,and my license is In pANEIs .'y,//b r n�/'��f0/i
=y Oemn Con 90 201�WO AMPS 51QYAd�-+++a�eGGG
1 ,z ARCHITECTS DEC SQ.FT.FLOOR AREA E/SQ.FT.
ZOm� OVER IOW AMPS
O Z—❑ 1 understand my plans shall be used u public a.
rn
W SIGNS ELECTRICAL
QyE'.�1 Licensed Profeuronal
�y.Ca OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
OaU I hereby affirm that I am exempt from the Coneracsors License Law for the
FLLOvr following n.(Section 7031.5,Business soul Professions Code:Any city or county TEMP.METER OR POLE INST.
,n which requires a Permit to convect,other,Improve,demolish,or ne . my awctuoe
C�>� prior so its trox.c.also requite Neapplictum fortmeh permiOe fit eaaigted a mem.I POWER DEVICES
pt eG a0C that he is licensed Pazuenno she pmviaiov of the Comracmrs Licevelaw(Chapter
a axxoV. 9(commereing with Section]OW)of DiviaionJ of the Businessand Rofessions Code) SWIMMING POOL ELECTRIC VALUATION
W_m
or he is exempt therefrom and Ne basis forthe alleged exemption.Any violation of
tZ< Second 703 L5 by any ap,li.1 for a Permit xubjmmthe epplicw 1.s civil pmelry of OUTLETS-SWITCHES-FIXTURES N,-11506�
not more than five hundred dollars(SSW).
K W NEW RESIDENTIAL ELECIR 5 .Ff.
Wim ❑ I,aaownemfNepmperry,mmycmplayeeswiN wegeautheirsolecompervasion, Q STORIES TYPECONSfRUCI]ON
a3L will dothewod,andthe sauaue isammunded conflicted forsele(Sm.7014,Business /
and Professions Cade:The Comracmrs Limnse Law does not apply In an owner of So/J rj
property whobuildsorimproves thereon,end whodoex such wads himselforthrough Me IG
wnemployms,pmvidedthassuchimpmvementsaenminendedoroffe for,ae.If, OCC GROUP RFS.UNITS
however,due
avet ngmden of proving sold
hewithin oteyem ar improve en.for the owner. TOTAL: /C/�f
builder will have the burden of proving that he did not build m improve for purpose of / IC_–
sale.).
❑ I.mmnerofthepropeny,amexcluxivclycono tingwithlimnsedconu tomto QTY' PLUMBING PERMIT FEE FLOOD ZONE "N
mnnmm the pmjmt(Sec.7019,Business and Professions Code:)The Convenors
LicenseLawdoesnotapply toenownerofproperry whobuilda orimprovo thercan,and PERMIT ISSUAN E
whoconeectsforsuch pmjws with aconsracurrfe)licensed puna anuothe Concrcmr's n
License Lew. ALTER-DRAT &V -WATRR(EAJ FEE SUMMARY
❑ 1 am exempt under Sec. .B&P C for this reasonBACK FLOW PROTE :DEVICE 11 OUT IDE FEE
Owner I Y Y—N
—
ION
DRAINS-FLOOR.ROO ,AREA,COND. RF.CEIPfp
WORKMAN COMPENSATION DECLARATION SC LTA YN
❑ l hereby affrrmthas l have acenifiwwofconsenuoaelf-imurc,oramrtificmeof FIXTURES-PER AP p{i1C RECEIPT'#
Wmketa'Comprnrasinn lruuranm macmificd ropy thereof(Sec.3800,Lab C.)whicIt PARK FEE Y N
covers ail emplo GAS RECBIPI'#
JOSE re# EA.SYSTE C.4OI1 CM
BUILDING DIVISION FOES
❑
Company
py is ere famished.
tifiedco GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
h
❑ Certified copy is fled with Ne city inepmtian division GREASWINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thosectionneednot ompleted ifthe thrond is for one hundred dollars(SIW) SEWER-SANITARY-STORM FA.2WFT. ENERGY FEE
or leas.)
(certify thatin@rep o tante of sitlwyknr whichthia permitn issue Is II WATER HIiATER W/VENT/ELECfRnot employ anY a �n m tto become sublect m t PAID
Z Compensation La n'ami m De WATER SYSTEhI/T'REATING - Date Receipt#
O APPlicent
NOTICE TO AP A T:If,after inghi nifmate of Exempdmr,ycu should NEW RESIDENTIAL PLM, SQ,FT. TOTAL:
FNi become rahjecno the Wmkcls Comps an sirens of she labor Code,you muss
forthwith comply with such provisions o m permit shall be deemed revoked. BUILDING FEE
yW Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that there is a construction lending agency for the performance of
U O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
Lender's Nemo
Lenders Address QTY. MECHANICAL PERMIT PEE PLUMING FEE
U
U I certify that I have rend this epplicumon and arae that the above information is
correct.Iagree to comply withal]city and county Ordinances and acme laws mining to PERMIT ISSUANCE MECHANICAL FEE
building construction,and hereby authoriso mpmsenwuves of this city to enter upon Ne
U Z above-mentioned property Por inspec'on puryoaes. ALTER OR ADD TO MECH. CONSTRUCfIONTAX
(We)agree m save,indemnif an eeI hmmless the City of Cupertino against
liabiliI
cosseand ex w 'ch may in any wayaceruea ho id Ciry AIR HANDLING UNIT(TO 10.00 CFM7
in cons f se granting t.
AIR HANDLING UNIT(OVER IU,OIq CFM)
Signet plicanVCan Tj
1Date EXHAUST HOOD(W/DUCq
PAID
HAZARDOJW&MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dae sed It
Will the applicant or for=building Occupant stare or handle hanodous material
as defined by the Cupertino Municipal Code,Chapter 9.12,end the Health and Safety HEATING UNIT(OVER 1 WpW BTU T
Cade,Section 25532(x)?
❑Yes 0 N VENTILATION FAN(SINGLE BESIDE
Willthea lice torfummbuildin occu BOILER-COMP OHP OR 100,000 BTU) ISSUANCE DATE
PP g pantay equipmentQ deity Mmul,rorm P A p D
h mous au conmmivnts as defined by the Bay Arta Air Quality Managemem BOILER-COMP(OVER 100,000 BTU
ismn?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. WAY
Y 1
I have read the h oust mamri requirements under Chapter 6.95 of she rIi'H 1994
California Health Sefe C o e.Stasi s 5,25533 and 25534. 1 understand tot O f�1 1`,
ifthe building does mcu m have moan that it is my responsibility nni ythe CITY OF CUPCNI
occupant of the ire is hich met prim m inuaace of enifi se of
Occupancy
Ownttm.Uflm agrn 1 1. TOTAL: ISSUED BY: