26399 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO -.1M FRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL, fJ[♦ (J (�
IN__I
UDI N_rjPR_OJKCIJIDENTIFIC_A_TI1) L v J J
BUILDING ADDRESS: SANITARY NO. APPLICATIO1N/S�UBMI'ITALDATE
21 �9S • QH UNITN LOT N' `SIN
OWNERg NAME: PHONE: CONTRA 'g NAME: Al. LIC NO: NIC CONITtOLN
S3— Ac ( r eC. ciZi-yb
ARCHITECT/ENGINEER: LIC NO: ADDRESS:
FCONTA�. PHONE: �pT;y�/� BUILDING,P,ERMffRI �,O °Stay:'"V
�� 8L8GITtI PERMIT' EFF—EEM
BL ELECT PLUMB MECII
PERMITISSUAlum ❑ ❑ ❑
SED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOBDES
WOOti 3afun tbvedunss provisifesions Code, nd mmecense with �w^MO&Zn 3ofthe Business and isionsionr Cade,andna license wa in pprygLg
FQb UPT0200AMPS
Lx.#_
yQy Dale i Contract lG s a4r�L4'T
201-IOo0AMPS
SQ.FT,FLOOR AREA USQ.FT.
ZFON'y ARCHITECTS DECLARATION OVER 1000 AMPS r
OZ� ��undedmy pl `114yier public obs.
�� `` SIGNS EIF,CTRICAL F Ips I'�''
- ifansal Pmfesaionu I -� r'„ L
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
xp 011U I hereby affirm that I am exempt found the Commctors License Law for the I IUU,,✓✓ ��
vJ 3 LL y fallowing reason.(Section]031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST. ' r✓' �� I
A which tortures n Permit to construct,alter,improve,demolish,or repair any structure
}�
pd.,o its iuuance,.P.requires the applicant fmatch pemdo to file.signedsta¢ment POWER DEVICES
O ohm he is]weaved p....a,mare provisions of an,Comracror.License law(Onspno
aoP' 9(cnmmencing with Section]o00)of Division Sof Ne Bnsimmaand Professions Cade) SWIMMINGPDOLELECfRIC L
�_rn or that he is exempt therefrom and the basis for the alleged exemption.Any violasion of OUTLETS-SWITCHES-FV(TURES ' s
Z 6 Section]03 L5 by any opplicant far a permit subjects the applicant ton civil penalty of
not mese than five hundred dollars($500).
NEW RESIDENTIAL ELECfR S .FT.
tem ❑ I,esawnerofthepmpcny,armyemploymewioh wages nsoheirsolecompewdon, Q STORIES TYPECONSTRUCI'ION
p, will do the work,and the svucmmis not imenlmoraffcred fnsale(Ser.904q Business
and Professions Code:The Cnmmetors License Law does nm apply to an owner of
property who bud] orimprovesthmrm,and whodoes such workhimselfmthmughhis
Own employees,provided that such improvements are notimenbodoruffendfor We.If, OCC.GROUP RES.UNITS
however,the buildingor improvement is sold within ane yearofcompletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
ale.).
❑ I,esowneroftheproperty.emaclusivdy convecting with licensed conuacton to 'T PLUMBING PERMI FEE FLOOD ZONE APN
construct the project(Sm.7044,Business and Professions CWep The Connector's PERMIT ISSUANCE
License Lawdocsnot apply manownerofproperty,whobuildsm improves thereon,and
whocommcosforsuch pmjmu with acuntracmr(s)licensed pursuanuo the Contractor's
Lic....Law. ALTER-DRAIN&VENT-WATER(EA) FBE SUMMARY <43.'FHGTl'.:`38°r
❑ 1 am exempt under gee. .B&P C for this reason BACK FLOW PROTECT.DEVICE - OUTSIDE FEES
SANITARY YN
Owner Date RECEIPT If
RKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOLTAX Y N_
❑ Iherabyaffirmt (haveeartificnm of amsem myyR-Ihmra,mitccrdfem.4 FIXTURES-PER MAP RECEIP #
Worken'Compenution trance ornttdBhxfcopy eof(Sec.3g00,Lab CJ which PARK FEE Y N
covers all am, '.aunder 's permit. GAS-EA.SYSTEM-IINC.40UTLETS RECEIPfp
bey. BUILDING DIVISION FEES
Company GAS-FA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cenifiedcopy is hereby fundi
El Certified copy is filed wi ecity ins 'on division. GREASMNDUSTRL WASTE INTERCEPTOR GRADING FEE
CTiRTIFICAfE OP EXEMPTION WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURA
GRossectionresdambecompletedifthe Fermi,is res dreddollars(flo0) SEWER-SANITARY-STORM EA.200PT. ENERGY FEE
Or lass.)
I country that in the performance of the work for which this permit it issued,l shall WATER HGTER WfVENT/ELECIR
nor=Ploy
m{yaperam In}seIly�a. Dae sM �beco�e!ubjgct�tLre Work.. WATER SYSTEMHREATING PAIDCompgDate Rueiptp
O z Applicant Ae r G 1/l ♦ �J
z0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
L� V] become subject to the Workers Compensation provisions of the Labor Code,you muco BUILDING FEE
comply with such pmvisiom m this pemdt shall be darned ravaged.ravaged.
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm new there is a construction lending agency fm the performance of TOTAL: ELECTRIC FEE
Q the work for which this pemdt is issued(Sec.3099,Civ.CJ
�+ lenders Name
0 [- Lenders AddressQTY. MECHgNIC A1,PERMIT FEE PLUMBING FEE
V 1 certify that I have toad this application and&me that the above in(otmetian is MECHANICAL.FEE
0. correct.I agree mcomply with all city and county ordinances and stare laws relating to PERMIT ISSUANCE
buildingcnnetrnsom,and hereby.uthodu representatives oftldschy mortar upon the CONSTRUCTION TAX
(j 7 above-memionW property for inspection purpmu. ALTLR OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in my way accrue against sold City AIR HANDLING UNIT(TO 10,000 CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10.000 CFM)
Signature of Applicam Commemr Data EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,001)BTU) Date Receipts
Will the applicant or future building occupant store or handle hmurdous mondial
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER I W,OW BTU) TOTAL:
Code,Section 25532(a)9 VW ILATION PAN(SINGLE RFSID)
El Yes A No ISS E
Will Jmapplicantorfummbuildingaccup t=s uipmentordevimswhichemit BOILER-COMP(3HP OR 100,000 BTU)
hturadous air❑comando utas defined by the Bay Arm,Air Quality Management BOILER-COMP(OVER 100,000 BTU) MAY� 19 ����
.
District? Yes No NEW RESIDENTIAL MECN. SQ.FT. A
1 have read the haysrdous materials mquirementa under Chapter 6.95 of the CITY yf t,
California Haulth As Safety Code,Sections 25505,M533 and 25534. 1 understand that VVr�I 1 I IIV(J
if the building does not currently have a tenons,that it is my responsibility to ramify the
occupant of the req ircmente which must be me prim m isaum�ce�oafa Cant ic.te of
axeas
r amhodrad.gen D TOTAL: ISSUED BY:
OFFICE
I