26957 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICA14
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 26957
BUILDING ADDRESS: / SANITARY NO. APPLICATION SUBMITTAL DAIS
.$T 1 N Ie A o P UNIT# LOT# ��../►
O ERS NAME: PHONE: CONTRACTOR'S NAME: LIC Nps N
O ) C d C ON 2aa D (`or4. SY 3b NIC CONTROL# Is
ARCHITECT/ENGINEER: LIC NO: ❑
C� ��� J u) I-e E' 1
G B T I�I C 0.-J a/�.� PHONE: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT MECH
PERMIT ISSUANCE'
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
qqqq tyy I hereby affirm that l an licensed under provisions of Chapmr9(commencing with
O Sermonsuband.f0ivisinn3of the Business and Profession, y,enyely license is in PANELS
full force effect O oG. '
License Class G.. 3 Lie.# UP TO 200 AMPS
of Data Comment, S AMP
2 FOy� ARCHITECTS DECLARATION 201-100OVER IO0 AMP00 S
SQ.Fp.FLOOR AREA $/SQ.FT.
O Z—G 1 understand my plane shall be used as public records,
r stn a SIGNS ELECTRICAL
q6,.J Licensed Profesaiunul
Ly�TZ Q OWNER-BUILDER fr DECLARATION SPECIAL CIRCUIT/MISC.
x 4 F 1 hereby n.(Se that I am exempt from the sC Contractors License Iso for the
following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
1❑"fh which requires n permit to construct,alter,improve,demolish,or repair any structure p
2 a� prior to its issuance,also requires the applicant for such permit to file a signed statement POWER DE CES I �.p
rr p
that he is licensed pursuant to the provisions of the Commators License Law(Chapter
d rL 9(commencin ith Section]o00 of Division 3 ofthe Business and Professions Code) SWIMMING OOL `CIRIC -
oy, Bw ) ) - `j VALUATION
W❑y or that he is exempttherefrom and the basis forthe alleged exemption.Any violation of d �
< Section 7031.5 by any applicant for a permit subjects the applicant a civil penalty of OUTLETS- -AIXTURE$
not more than five hundred dollars($500).
C2 I
c, ❑ I,asownerofthe t NEWRESM ALE
prone(y,ormytintemectorafoegesasshei(sole compensaneas STORIES TYPE CONSTRUCTION
pW, will dathewons Ccaudth Tire Contractor's
License fierad
fsact apply
to 44.Business __
and Professions dam The Cmnwror's License Law does not apply to an owner ofprop -
ownertywyeas,pdaoredthwasthimp cements awtintend orofffmthrough Ms
employeestiding rimprsuch impmvemwithin ne�ari edmplatred theo e.If, OCC.GROUP RES.UNITS
however,the have
the burden of emem is sold within one year of completion,the owner- TOTAL:
builder will have 1M1e burden of proving that he did not build or improve for purpose of
ale.).
❑ ns, he project
(Sea.property,=exclusively and contracting with dac) ed Consomme,
QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
mnswr the does not
apply
](w4.Business and Prohobuild Code:)The Contractors
License Law
ctsfor former
an owner whmedpsorimproves Commacand PERMIT ISSUANCE
whence Law.forsuch proju[s with acontrector(s)Iicensed pursunntro the Contrnemre ALTER (EA) PEE SUMMARY
l.ieenm Law.
❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOLTAX Y N
Jt IherebY affirm shatlhave emcniecam of consem[o self-Insure.ora wrtiflmm of RECEIPT#
' k'."a".Compensation Instantiate or a certified copy thoomf(Sec.3800,Lab C.)which FIXTURES-PER TRAP PARKFEE Y N
ol cyglee�s uotler{yisyT,lrn�. RECEIPT#
P
CCOO�r77V GAS-BA.SYST'EM-I INC.4OUTLETS BUILDING DIVISION FEES
C�omyany GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
LIF Certified copy is hereby famished.
❑ Certified copy is fled wish the city inspection division. GREASEINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thin section need not becompleted ifshe permit is forom hundred dollam($100) SEWER-SANITARY-STORM EA.200Ff. ENERGY FEE
or less.)
I certifythat in she performance ofthe work for which this Permit is isaued,Ishall WA TER W/VENT/ELECfR
not employ any Farm in any manner an as m become subject m she Wmher% PAID
O z Compensation Laosof California. Data AT TEMJMEATING Data Receipt#
Applicant
z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ,FT. TOTAL:
become subject an the Worker's Compensation provisions of the Labor Code,you must
forthwith comply wish such provisions or this permit shall be deemed revoked. lbrBUILDING FEE
Wz
CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a concoction[ending agency for the performance of
V O the work for which this permit is issued(Sec.3097,Civ.CJ ELECTRIC FEE
Lenderme
's Na
0 U Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
[Ta I certify that 1 have reed this application and stem that But above information is MECHANICAL FEE
street.I agree to comply withal]city end county ordinances and state laws relating to PERMIT ISSUANCE
buildingconstmction,mdherebyauthorimrepreaemmdvesofthi itytoemeru the CONSTRUCTION TAX
V 7 above-mentioned property for inspection purposes. /� ALTER OR ADD TO MECH.
F7 twa, agree ri save,indemnify and keep impar a F.pt f g
liabili(We)udgmems,coets andrmily an which may in c e d AIR HANDLING UNIT(TO 10,000CFM)
c nee pence of the granting of this t.
AIR HANDLING UNIT(OVER 10,000 CFM)
Smgnmre of ApplicanVContmon Due EXHAUST HOLD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 1 W,ODO ATU
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety )
Code,Section 25532(a)?
El Yes 11 No VENTILATION PAN(SINGLE RESID)
ISSUANCE DATE
Will the a licantor Armrcbuildin BOILER-COME(3HP OR 1011,000 BTU)
pp g by the
Are.Air Quality whichemit PAID
p�� pp pp�pp
hazurdous air comaminems as defined by[he Bay Aree Air Quality Management BOILER-COME(OVER 1100,04))BTU) P A E D
District? '
Cl Yes ❑No NEW RESIDENTIAL MECH. SQ.ET.
I have read the hazardous materials requirements under Chapter 6.95 of the AUG 3 0 199
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand that a7
if the building does not currently have a tenant,that it is my responsibility to notify she 1.
OccuCaney am u(the requirements which mot be met prior to issuance of a Cenificme of CITY f„r ....s
Ur Lu -I
Owner or authorized agent Data TOTAL: ISSUED BY:
OFFICE