26939 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOPERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL n C (]
BUILDING PROJECT IDENTIFICATION L o J
B ILDING ADDRESS: '/I UNIT N LOT
/D SANITARY NO. APPLICATIONSUBMITTALDAIE
NERS E:N /�� PHONE: C ACTOR'S NAME: LIC NO: N/C VVV CONTROL k
:RCH /ENGINEEER: LIC NO: ARE 7/231C.,
1 ❑
We I
co
w �J�PHONE: Q.I-Y ELECTRIC PERMIT FEE BUILDING PERMIT INFO
L / /T BLDG ELECT PLUMB MECH
PERMIT ISSUANCE -
LICENSED CONTRACTOR'S DECLARVHON APPLIANCES-RESIDENTIAL LOB DESCRIPTION
MW,z I hereby affirm that l am licensed underprovisions of Chapter9(commencing with
VCO Section 7000)ofDivision 3 of the Business and Professions Code,and my license is in PANELS
W W U❑ full force and eff 6eTY
aV License I s _Lie.# r Z� UP TO 2W AMPS
ti LTS D Con201-1000 AMPS
E'm �ARCHITECTS DEC TION SQ.PT.FLOOR AREA E/SQ.FT.
CZ220 on ma Alb us#iag lime OVER 1000 AMPS
F,4t, ns SIGNS ELECTRICAL
Q 0 Licensed fie Tonal
W V OWNER-BUILD ER DECLARATION SPECIAL CIRCUIT/MISC.
yx ty 1 hereby affirm(Se thin 1 am exempt from the Cont...Cc License Lew for the
00'3 WO y following reason.(Section 7031.5,Business and Ptvfessions Code:Any city ar counry TEMP.METER OR POLE MST,
co co rn which requires a permit to construct,alter,improve,demolish,or repair any etrucmre
Y� prior m its issuancgalso inquires theapplicautfor such permit to file.signed sentemrnt POWER DEVICES
G p that he is licensed pursuant m the provisions of the Contractor's License Law(Chapter
S ❑ 9 mmrncin with Section"/000 (Division 3 ofthe Business and Professions Code SWIMMING POOL ELECTRIC
40,' (th gwi )o ) VALUATY
iW^� or that h7031.5 by therefromandfor a baspermit forthetheaexemantto Anyviolationof OUTLETS-SWITCHES-FIXTURES CC//�`
GSection7031.5than bye ve undredicentrs($50rmit subjects the applicant ecivil penilty of ],�(J
G not more@anfi.fthipreddoll.rroyern). NEW RESIDENTIAL ELECTR -SQ.FT. STORIES TYPE CONSTRUCTION
❑ Lasowrk,anheestrucy,ormatimandialplaysuo wiNwodforsals stheirso.compensation,
a willdo thewmk,and the he Cireitcam'ntendede Law does ntapplytoan,Business
and proparty who
Code:The improves
tra0or s License Lew does not apply lm r owner of
ownemploy s.pmorimprovesthereo verveand tsmno does suintendch hi offemdf mMe.nuth hf,
employees,pmvidedthereucM1 improvementsnrenorimendedoroffemd fmsale.If, DEC.GROUP RES.UNITS
however,the building orimprevement is sold within one yearofcomplemn,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale).
❑ 1,asownerofthepopny,.mexclusivelyeontractingwithlicensedconv tomto QTY. PLUMBING PERMIT FEE FLOOD ZONE AHI
omumet the project(Sec.NWA,Business and Professions Code:)The Conrmcmrs
License Law does not apply to an owner ofproperry,who builds or improves thereon,and PERMIT ISSUANCE"
whocomractsforsuch projects wirhacontmcmr(s)licensed pursuant to the Contractors ALTER FEE SUMMARY
License Law. (EA)
❑ 1 am exempt under Sec. ,B A P C for the mason BACK FLOW PROTECT.DEVICE ORTESIDEMES
SANITARY YN
Owner Data DRAWS-Fl.O ,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATIONrIkOL YN
+I hereby affirm that l have a cenificate ofeencent m self-insure,or a cenificate of FIXTURES-P RT t r RECEIPT
#
'rketi'CompensationInsurance orecertified copy Hereof(Sec.3801 Lab C)which f" '. t A FEET YN
covers all employee's under this permit. GAS-EA.SYSimlvfi INC. OUTLETS". ' 1 RECEIPT*
Policy# A ✓ BUILDING DIVISION FEES
CompanyGAS-FA.SYS M, - R 4(FA) WAd
CHEEK FEE
❑, CeniBel copy is hereby famished. -
/TQviified copy is filed with the city inspection division. GREASE/IND I
TRI,WAEMgrLERCEPI'OR RADING E
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed if Ne permit is foronehundrW dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY PEE
O
l less)
I tinily thin in the performance ofthe work for which this Permit is issued,l shall WATER HEATER W(VENT/ELECTR
not employ my action in any mariner so as m become subject to the Workers' PAID
7-. Compinsation"vesof California. Dam WATER SYSTEMH'REATING mm Receipt#
Applicant
Z NOTICE TO APPLICAW-.If,after making this Certific.m of Exemption,you should NEW RESIDENTIAL PLMH. SQ. TOTAL:
f"' h become subject to the Workers Compensation pLabor Code,ofthe LaCode,you must -
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
Q
CONSTRUCTION LENDING AGENCY SEISMIC FEE
7-.
1 hereby eff that there is a construction lending agency for The perfomtsnce of TOTAL: ELECTRIC FEE
U O the work for which this permit is issued(Sec.3097,Civ.C)
Fkn Lender's Name PLUMBING FEE
0 U Lenders Address QTY, MECHANICAL PERMIT PEE
1 certify that I have read This application and stem Net an above information is
aburred censer comply and ordinances ofthis state out r ming to PERMIT ISSUANCE MECHANICAL FEE
UZ
building
-mmu construction, frinspectionprcpnces. Lives ofthiscirymemerupon the CONSTRUCHONTAX
U above-memigave properly for inspection purposes. ALTER OR ADD TO MECH.
(W agree m gave,indemnify d keep harmless the City of Cupertino against
liabilis ' dgments,costsandex meswhichmayinanywayaccrae eppidid said City AIR HANDLING UNIT(TO 10.004 CFM)
ire ae the ego thisp V/p/
1 AIR HANDLING UNIT(OVER 10,000 CPM)
ignatureof Applician Contractor Date EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000 BTU) Dam Receipt#
Will Lha the Cuanttino Mu building eventual Chapter
or handle Health asmamriel HEATING UNIT(OVER 100,0008TU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Crda,9animn 25532(a)R
Cl Yes ❑No VENTILATION FAN(SINGLE REBID)
�
ISSUANCE DATE
Will air contammfumrcbufned occupantay equipment unlit resaregammlt
BOILER-COMP IMP OR 100,0 a)BTU)
hnzardous air contaminants as Defined by the Bay Area Air Quality Management
s1'vcCl BOILER-COME(OVER 100,0110 BTU)❑Yes 11 No NEW RESIDENTIAL MECH. SQ.IT. P A @ D
I have read the hazardous materiels requirements under Chapter erst of the AUG ����
California health h e hely Code,Sections 25005,25533 and 25534.Ch L understand Thal
if the building does not currently have a meant,that it is my responsibility to notify the
occupem of the requlremrnts which mus[be mu prior m issuance of a cenificate o[ /�
Occupancy, Vll Y Ur , sl
Owner or authorized agent Data TOTAL: ISSUED BY:
OFFICE