26864 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF,CUPERTINO , ..qL.ma17-.j,.1FRJCAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. n[x O�+ /I
BUILDING PROJECT IDENTIFICATION G 6 o v 4
BUILDING-/A/ADDRESS: y SANITARY NO. APPLICATION SUBMITTAL DATE
OUNIT# LOT `�
OWNE NAME: PHONr. CO�ACfOR'S NAME: LIC NO:
EV/ NIC CONTRO
RC T/ENGINEER: LIC NO: ADDRESS: ❑
O ACT: PHONE:
QTY, ELECTRIC PERMIT FEE BUILDING PERMIT INFO
PERMIT ISSUANCE BLDG ELECT PLUMB i MECH
LICENSED CONTRACTOR'SDECLARATION pppLIANCES-RESIDENTIAL OB DESCRIPTION
p y.Z
Thereby affirm T [amhat licensed uACTORvisDECL %TIO9(commencing with 'pNaYt�y'
0O Section 700r)of Division 3 ofthe Business and Professions Cade,and my license is in PANELSOP
y U E full farce and effen. )
FZ41 License Lie# UP T0200AMPS
y6y pate Conlracmr 201.1000 AMPS r
ZOy ARCHITECI"S DECLARATION OVER IWO AMPS SQ.FT.FLOOR AREA E/SQ.PT.
O Z—❑ I understand my plans shall be used as public records.
<= Lit SIGNS ELECTRICAL
y ,"yj Licensed Professional
�KaU OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
Od an I hereby affirm that I am exempt from the Contractors e:Any
Luo for my
413 O rn following reason(Section 7031.5,Business and Professions Code:Any city s county TEMP.METER OR POLE INST.
fS y which mquims a permit m conabuck after.improve,demolish,or repair any structure
> that he s licensed Tumoral alto the
tprvisios of the Cotrretitm License
smhapter POWER DEVICES
00 thatheisncensedtotheprovisionsof the the Business License Law(Chapter
L o ' 9(commencing with Section 7000)of Division 3of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
or�y Seen 7031.emptapplicant
f the basis for exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
Semon]than
TO,.,hundred rich.
subJects thenpplicenno aaivil penalty of
O na more then five hundred dollars($500). NEW RESIDENTIAL ELECfR _SQ.FT.
❑ LThewrk,adreproermotimenyewwithw.gesasthei(Sec.compensation, STORIES TYPE CONSTRUCTION
a will do The won,nod thehe Costructure lsnoHs License
Lae does not
apply to
wo Business
and Professions Code:The ves Contractor's License Law does nor apply to an owner of
pTuownertywyees,pmvidedpat.eutherepovemenoamnsuintend oroffmdforughhis
employeea,providad Thetmch impi...Id within
a earl cripladiv,forsale.If. OC .GROUP RES.UNITS
buwevegillhave the
burimprmementishat he ii not build of completion,Thepose of TOTAL:
builder will have the burden of proving that he did not build or improve for purpnu of
ale.).
❑ Las owneroftheproperty,nmexclusively contracting with licensed contractors. QTY. PLUMBING PERMIT PEE FLOOD ZONE APN
cousova the project(Sec.71144,Business and Professions Code)The Contractor's ppggylT ISSUANCE ��
License Law does not apply to an owner of pmpery w ho bu it ds or ,improves thereon,and
who contracts for such pmjects with acontracmr(s)licensed pursuant ethe Conmmusirs ALTER EA
License Law. ( > t�Ey
UMMARY
❑ I an exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE DOSID FEES
N
Owner Dow— DRAINS-FLOOR,ROOP.AREA,COND. ECEIPT#
WORKMAN COMPENSATION DECLARATION N
❑ Ihereby effemthat lhave acertificate of consem.self-insure,urn cerdfcae of ECEIPT#
Workers'Comisomation lnsurenceor a certified copy thereof(Ser.3800,Lab C.)which FlXTURES-PER TRAP Y N
Polcy#I emp�uade dhlsne®tECEIPTN
!J 371.5 GAS-EA.SYSTEM-I INC.40UTLETS ' DIVISION FEES
ormnny T76 GAS-EA.SYSTEM-OVER 4(EA)
❑fenified copy is hereby fumished.
Certified ropy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GFASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This seemirticednm be completed ifthe Permit is Tomos hundred dollars($100) S WE SA 1'IIARY-STORM EA.20ENERGY FEE
IT a
or less.)
I certify thin in the Performance ofthe work forwhich this permit is issued,l shall +T!EffilgkER W/VENT/ELECTR ,I
not employ any person in any manner so as to become m tire e Workers' PAID
Compensation Lawsof Califaram. Data TER STEMOREATING ® F Dam Receipt#
Z Applicant qt
0 NOTICE TO APPLICANT:If,afer making this Certificate of Exemption,youidauld N WRESIEWIEP TOTAL:
Vibecome subject a the Worker's Compensation provisions of the Labor Code,you must
LLL^^^ forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
7
QCONSTRUCTION LENDING AGENCY SEISMIC FEE
7
1 hereby affirm that There is a construction lending agency for the performance of ELECTRIC FEE
V O the work for whi h his permit is issued(Set.309],Civ.C.)
H PLUMBING FEE
Lender's Name
O F Lender's Address QTY, MECHANICAL PERMIT FEE PLUMBt
V I certify that I have read this application and smte that the above information is
correct legree to comply with all city end county ordinances and state lows relntingm PERMITISSUANCE MECHANICAL PEE �g
Ln building construction,and hereby anthem representatives of This city to enter upon The CONSTRUCTION TAX
U 7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
G (We).gree to save,indemnify and keep harmless the City of Cupenirm against
Bahr'ties,judgmarl"civtsand expenses which may in anyway acme against said City AIR HANDLING UNIT(TO 10,000 CFM)
in om quen of The granting of panni[.
AIR HANDLING UNIT(OVER 10,000 CPM)
tura of Applicant/Contractor 100,
Date EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 108000 BTU) Dam Reo iptIf
Will the.pplicant or furore building cau.par Nee or handle hazardous mamnal HEATING UNIT(OVER 100,000 BTUj GTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and The Health and Safety
Code,Se fon 25532(e)?
11 Yes El No VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
Will thea licanmrfumrebuildin Deco ruse mrdeviceswhichemit BOILER-COME(3HP OR IOO,gq BTU)
pp g pan equipmen
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COME(OVER 100,0(i BTU)
Distrin?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.IT.
1 have mud the hazardous materials requirements under Chapter 6.95 of the AUS' 11 199
C.lifornia Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that
ifthe dingdoes not curre 11 h ve a mnar.that it is my responsibility m notify The
oecu oft repti t to is of enificete of TV UI' I+Uf' tV
Gcen n V 1
nuthonzedagem pure T ISSUED BY:
OFFICE