26296 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO "UILIVING-R al AL PERMIT No.
PLUMBING MECHANICAL
BUILDING DIVISION APPLICATION/PERMIT BUILDING PROJKC11DEN1IFICATION 26296,
,
WILDING ADDRESS SANITARY NO. APPLICATION SURmnT7ALL VAIL
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ONTACT: PHONE:
QTY, ELECTRIC PERMIT FEE BUILDING PERMIT INFO
' RI.DG ELECT PLUMB MECH
PERMIT ISSUANCE zrQO ✓I IC/I 13
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DFSCRI ON
❑WZ Thereby aftnmNatIarm licensed underprovisionsofChapter9(commencingwith {�Q S�L(� lbFtY
iW OO Section]000)of Division 3 of the Business and Professions Code,and my licemu is in PANELS
FF v1 L Il f itIT
Lic.M
ZuZ �'nL af�(/ UP T0200AMP5 MSlR- (}�q e�a�^D•��—
6 Z
Date ARCHITECT DFC RATI N-�+D"" 201-I WO AMPS Jar_ Y
SQ.FT.FLOOR AREA SISQ.PT.
OZ-0 I understood my plans shall be used as public records. OVER I000 AMPS
ver Fo lel SIGNS ELECTRICAL
ftA� Licensed Professional
w< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XiU I hereby affirm that I not exempt from the Contractors License Law for the
n13 R.ti following lesson.(Section]W 1.5,Bulinus and Profusions Code:Any city calumny TEMP.METER OR FOIL'INST.
which reyvims r permit ne imes th r alto,improve,demolish,or leash any swmurc
prior to issuance,also requ'..a Ne appliesres for such pewiuo rite a¢igrrd statement POWER DEVICES
sY p„[0 p that he is licensed pursuant to the provisions of the Convectors License Low(Chapter SWIMMING POOL ELECTRIC
a'aX'Xo�' 9(commencing with Section]000)of Division Jofshe Business and Pmfeasions Code) ' ` VALUATION
,,rthattiscthemfirmmadthe basis gedexem"mn.Any violatonof
pplicant
u%:>
Section 7031.S by my ant fm a perrutsubjects the o3. ciy OUTLETS-SWITCHES-FIXTURES IL�)AL/
no,more than five hundred dollars($500).
m 11I,asownerof Nepropony,ormyemployeeswithwagautheirmlecompemmion, NEW ftESIDENTIALELECI'R —SQ.FT. STORIES TYPECONSTRUCTION
a.3— will dothe work,and thesvuaumis not imandedorffered for sale(See.701 Business
and Profesia oto Cale The Contr¢cmrs License Law dos not apply in an owner of
propenywhobuildsorimpmves Hereon,undwhodmssuch workhitnselforthmughhis
wnemployecs,p oriNet¢uehimprovememsarene ear ofcompleered for sale.If,
OCC.GROUP RES.UNITS
howeverillhabuilding teburden of pmentishin he
root build or improve foron.theawna- TOTAL:
builder will have the burden of proving shat he did not build or improve for purpose of
le.).
❑ I,uownendthepmperry,em cxclusivelyconvacting wiNlicensedconw<mn to QTX, PLUMBING PERMIT FEE ROOD ZONE APN
cnnswtl the project(Sec.7044,Business and Probation.,
Code:)The Contractors
Lic<nx law dman,,t applym¢nownerof propenywh,,buildsorimprovu Hereon,and PERMIT ISSUANCE 3.Zs 00
who contracts
forsuch pmjurwiNonvmr(
ncacs)licensed pursuamlathe Contractors ALTER-DRAIN&VENT-WATER EA) a � FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this reason BACK ROW PROTECT.DEVICE F
SANITARY Y N
(Avner Datr DRAINS-FI.00RROOFAREA,COND. RECEIYI'N
, ,
WORKMAN COMPENSATION DECLARATION . SCHOOL TAX Y N
❑ l thereby tifimm that l have a cenificuteofconsam m self insum,or certificate of FIXTUR[S-PER TRAP RF.CF.IPT#
Workers'Crnpemetion lnsuranceon ceru0cd copy thercof(Ss.3g00,LebCJwhich Or PARK FIDE Y_N
covers all employer's under this permit. GAS.EA'.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER4(EA) PLANCHECK FRE
❑ Cenifedmpyisherebyfumished.
❑ Cenified copy is filed with the city inspection division. GREASPANDUSTISL WASTE IM'ERCF.PfOR GRADING ME
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASCTRAP r p t
COMPENSATION INSURANCE
(ThissectionnceJ nm ate completed if she permit is forone hundred dollars(5100) SEWER-SANITARY- 2 FTYFEE
or leas.)
I cenify that in the Performance of the work for which this permit is issued,I shall WATER IJCATER WN' L
not employ any person m any manner so u so ern i mbiat In tl Work,,a P
Compcnsetion Laws hfomie. Da¢ U WATER SYSTE FAU am Receipt#
ZZ Applicant
0 NOTICE TO AP :If,after making this Certificate of Exemption,you should NEW RESIDE B. SQ.PT. TOTAL:
l—� (4 become subjauo the Worker's Compensation provisions of she Labor Coda youn—,
I--' - forthwith comply wiNsuch provisions ar this permit shall be dcemal revoked. BUILDING FEB a c49
0. [� CONSTRUCTION LENDING AGENCY SEISMIC FEE ]v r
Uz I hereby affirm that there is a construction lending agency for the performance of
O Ne wmkfor which this permit is iuuwi(Sec.3097,Civ.C.) TOTAL: ELECIRICME VQ
Lenders Name
OF Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING RE `r
U I certify that 1 have lead this application and arta that the above information is MECIIANICAI.FEE
correct.l agree to comply with all city and county ordinances and state laws testing to PERMIT ISSUANCE.
buildingcomniction,mrd hercbyaulaid.represenrtivesofilocity toenterupomhe CONSTRUCTION TAX
V 7 abme-mentinned Property for inspection purposes. ALTER OR ADD TO MECH.
rte- (We)a,.m ass,indemnify and keep hom hos Ne City of Cupertino against
liaM1ilities ' srerWes a suwhichr in any way eecmeagainst s�idCity AIR HANDLING UNIT(TO IO,IXI)CFM) ` S i
in conseyuc eof+he�of emsit. AIR HANDLING UNIT(OVER 10,000 CFM) A. 7S o0
Signaturcof ApplicanUCommitor�Dare-Date EXHAUST 11COD(W/DUC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building occupant store or handle housrdoua mataid HEATING UNIT(OVER 100,000 BTU) TOTAL: /
as defm¢aI by the Capacious,,Municipal Code,Chapter 9.12,and the Health end Safety
Cale,Section 25532(.)]
❑Yes )16. VENTILATION PAN(SINGLE RESID)
ISSUANCE DATE
Will theapplicemorfuture buildingmcupamuseequipmcmmdevicu whichemit BOILER-COMP QHP OR 10ILM BTU) r p�� p p D heaardam t¢
air conminenrs as defined by the Bay Are.Air Quality Management BOILER-COMP(OVER 100.000 BTU) Y's Y V
Dismo?
❑Yes �N. NEW RESIDENTIAL MECH. SQ,FT. R 22 1994
I have read the haeandoi s materials requirements under Chapter 6.95 of the APR
California Realth&Safety Code,Sections 25505.25533 and 25534. 1 understand that
if the building does not curtcmly hav renanh hi¢my reaponmbifitymnatiry the Cll lr Ur kNUYtnluvU
occupvnt ofrtLT!lfaftineli is who ust be c prim m issugm9e o ^ m mTWe of
tYcupency. � 6i\� d,j„i1V1
Owner,,r authored agent Date TOTAL: ISSUED BY:
OFFICE