26248 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES.USE BALL POINT PEN ONLY -
CITYOPCUPERTINO BUILD( -ELLE TRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING ADDRESS: BUILDING PROJECT IDENTIFICATION 26248
SANITARYNO. AFPLICADONSUBMULALDATE
UNIT# - LOTN f \_Ck
O E N MT. LICNO:
violNE: RA N IC NO: ^ `/� —V��
J7 N/C CONTROL N.
RCHITRUI'/ENGADDRESCONTACT: NE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ El LICENSED CONTRACTOR'S DECLARATION
APPLIANCES-RESIDENTIAL
F100 Thereby ofirmthatl emlice Business it Prodfisof Chaode, nd my he..gwith - JOB DESCRIPTION
F100 Op Seniors a and of Division 3 of the Business and Professions Cade,end my license is in PANELS
y�trJ full force and effect
y Dale se Class Co�#ncmr R 7/ UP TO 200 AMPS
201-IIXq AMPS
FN4 ARCHITECTSDE E/SQ.FT.
Z8,-4 Z I understand my plans shall be used as public records, OVER 1000 AMPS SQ.FT.FLOOR AREA
rr 4Y �4 SIGNS ELECTRICAL
90 Lmensed Professml
aa
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
M O a F 1 hereby affirm that 1 am exempt from the CmntractarR License Law for the
3 rn fallowing reason.(Section 7031.5,Business and proposed.,Cade:Any city or county TEMP.METER OR POLE INST.
s g which requires a permit n construct,alter,improve,demolish,or repair any structure
yoeaY� #norm its insurer,also requires theapplicut forsuch penniltofileaaigmednatemem POWER DEVICES
C p that he is licensed pursuant to the provisions of the Contractors License Law(Chapter - -
go�' 9(commencing with Section 7000afDivision 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC ' '
W.—w o,the,he is exempt therefrom and[he hash,1,the alleged exemption.Any violation of VALUATION
Y Section 7031.5 by any applicant for a Mount subjects the applicant o a civil penally of OUTLETS-SWITCHES-FIXTURES
Q not mom than rive hundred dollars($500).
�p ❑ 1,mcovneroftheproperty,ormyemployeeswithwegesastheirsolecompensation, NEW RESIDENTTALELECIRSQ.FT. STORIES TYPE CONSTRUCTION
will do the work,and the structure is not intended moffered far sale(See,7094,Business
and Professions Cade:The Contractor's,License Law does not apply to an owner of
propertywhobuildsorimprdves therem ,and who does such wo1khimm1forthroughhis
ownemployees,providedthatauchimprovements arenatirearded m offered insole.If. OCC.GROUP RES.UNITS
however,the budding or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of TOTAL:
sale.). -
❑ I,.sowacrofthepropeny,emexclusivelyconuactingwithlicensedconuac[orate QIPLUMBING PERMIT FEE FLOOD ZONE APN
tower the Prefect(Sec.7044,Business and Pmfesamas Code:)The Con[racror's
License Law does not apply roon owner ofproNny who builds mimprovesthereoa,and PERMITTSSUANCE
who contracts for such projects with.containments)licensed pursuant to the Common?,
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
111 sm exempt under See. •B Be P C for this named
BACK FLAW PROTEGE DEVICE UTSID•FEES
Owner Date SANITARY Y_N
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,EDGE,AREA,COND. RECEIPT#
I hereby affirm that l have a certificate of consent to self-imare,car a eenifirme of SCHOOL TAX Y N
ars'Compensation insurancenifiede ivy timnewSee.3800,Lab C.)which FIXTURES-PER TRAP RECBIPI'N
wversall an{y t uti 0O �l PARK FEE Y N
Policy# c GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
CompanyBUILDING DIVISION FEES
nified copy is hereby famished. Ogg 00 1 GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is filed withthe city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATEEXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not becomplued iftheperrnit is for now hundred dollars($100SEWER- A RM EA.200FT. ENERGY FEE
or lase.) •
(certify that in the performance of the work for which thispermit is issued, ail W 11 ENT/FLECR I
not employ any person In any manner ao As to become subject m the W ars' PAID'
z Compensation Lawsof C.lifomla. Date A RSYSTEM NO
Applicant Dote ReceiptN
Q O
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you she d NEW DENH B. Q.ET.
(n become subject to the Workers Compensation provisions oflhe Labor Code.you t TOTAL:
Ij forthwith comply with such provisions onhis permit shall be deemed revoked.
BUILDING FEE
a FQ• CONSTRUCTION LENDING AGENCY SEISMIC FEE
'Uz Ihereby affirmthatthe.is a commeation lending agency for the Performance of
U Q the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
{Ir Lenders Name
Lender's Address FEE PLUMBING FEE
O QTY. MECHANICAL PERMIT
I certify that 1 have read this application and sten that the above information is
correct.I agree to comply with all city and county ordinances sod state laws relating to, PERMIT ISSUANCE MECHANICAL FEE
Cn building commclion,and hereby audemix representatives ofthis city to enter upon the O
L) 7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree to save,Indemnify end keep hurmlesa the City of Cupertino against
Iiabililies,judgmems,ciousand expenses whichmay in any wayaccme against said City AIR HANDLING UNIT(TO 10,000 CEM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of AppbunUCamantor Date - EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) 00 Date Raeipt N
Will the applicant or future building occupant store or handle hazardous maim.l
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOT
Code,Section 25532(a)'1
❑Yes NONta VENTILATION PAN(SINGLE RESID)
BOILER-COME OR HE,000 BTU) yC DATE
WIII Neepplicamm(mare buildingoccupan[oseequipmemordeviceswhichbmit ppaa !L/J
heurdoue air contmninan[s as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100.000 BTU)
/
Districp (s a�
❑YesNo NEW RESIDENTIAL MECH. SQ.ET. VM
I have read Safety ndousCode,materials 5505,25533 under 34.Chapter1 un erst of the - 199�
California Health&Safety Code,Sections 25505,t itis and 25534.I understand that ±,Uh lNUrr�YIlry
ifthe bailoftheng rsaotcurrcmly haveatt asmet itis my responsibility moodily the at of the requireme is icb must be met ro issue ce of a Certificate of
O cu s
Date TOTAL: � ISSUED BY:
OFFICE'