26301APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO DINirEI- .
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT WENT IFICATION
PERMIT NO.
26301
D UILDING ADDRESS:
SANITARY NO.
A1PPILKIV IONSUBMITTALDATE
/ — a UNIT# LOT
OWNS NAME: PHONE:
+
CO ACTOR'g NAME: LIC NO:
N/C
CONTROL #
CII :CT/ENGINIiER: LIC NO:
ADDRESS' /1
t /�NIf
❑
'OMfACf: PHONE:
QTY S+" BLELTRIC(PFRMIT�, - FEE-
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
PERMIT ISSUANCE
El F-1 0
- LICENSED CONTRACTOR'S DECLARATION
byffi
I herearm that l am licensed underprovisianaof Chapter9(commrncingwith
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
PANELS
UP TO 200 AMPS
Section 700J)af Division 3ofthe Business and Profeeions Cade, and my license is in
full farce end eB
License Cl Lica
201- I"AMPS
Date Comrector
ARCHITECTS DECLARATION
SQ. FT. FLOOR AREA
E/SQ. t't'.
OVER 1000 AMPS
1 unde nd my plans roll be used m public records.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
I hertby mE. Nal I am exempt from Ne Contractors License Law for Ne
fallowing reaarm Section 7031.5, Business and Professions Code:Anycitymccunty
'
TEMP. METER OR POLE DIST.
which mquires a Permit to conseum, alter, improve, demolish, on repair any structure
prior to its issuance. also require the applicant for such permit to File a signed statement
POWER DEVICES
that he is licensed pursuant to the provisions of the Connectors License Luo (Chapter
9(commencing with 70G()heO sisior 3oflleedHummus
sola Code)
SWIMMING POOL ELECTRIC
VALUATI<jn�.
erSection
exemption. Any
he is exempt therefrom and the basis for the alleged exemption. Any l violation of
Sor ection
Sxtian 707 LS by any epplicanrtorapermit subjemsthe applicant toecivil penalty of
OUTLETS -SWITCHES -FIXTURES
na more Nun Eve hundred dollars (S500).
❑ I.asownerofthepropeny,ormyemployeewithwageetheirsolecompensstion.
NEW RESIDENTIAL ELECIR _SQ. FT.
STO IFS
TYPE CONSTRUCTION
wi l l do the work. and the suuc tum i s not intended m offered for ale (Sm. 7044, Business
and Pmfessimx CMB: The Cmumm's License Law does not apply to an owner of
property who buildsor improves thereon, and who does such work hinvelfm through his
own employee, providedidauuch improvementsarcnot intendedoroffeed Succeeds. If,
however, the building orimprovement issold within one yearo(completion, theawner-
OCC. GROUP
RES. UNITS
TOTAL:
builder will have the buNm of pmving that he did not hold m improve for Imports, of
QTy. i PLUMBING PERotsaFEEF1O0D
LONE
APN
sale.),
❑ LnowneroftheproPenY.amcaciuovelycontrvctin8 with licensedcontrectomm
construct the project (Sec. 7114,1, Business and Profession. Code:) The Contzeaar'a
License lawdae not epplpo anownrof property whobuildsmimproveathcrem,end
,
PERMIT ISSUANCE
who connects forsuch Projects with acomactor(s) licensedpursuant tolle Contractors
License law,
ALTER - DRAIN @ VENT -WATER(EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OU SI
❑ I m exempt under Sec. . B & PC for this reason
SANITARY Y N
RECHIPTN
Owner Da¢
DRAINS- FLOOR, ROOF, AREA, COND.
-
WORKMAN COMPENSATION DECLARATION
Q n Thereby afFlmrthatl heveacertifceu of eanunttoulGinmrc. arecenifice¢of
mkeOr Compensation Immarcearacertifind copy thereof (Sa.IBOO,Lab CJ which
moveallemployee's under this .it.
Policy #
SCHOOLTAX Y_N
RECEIPT#
FIXTURES - TER TRAP
PARK FEE. Y N
RIVISI N
GAS - EA. SYSTEM -I INC. 4 OUTLETS
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCIIECK FEE
❑ Ccnlfied copy is hereby famished.
GREASEBNDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Cenifedcopy, is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY HE
(This section need notbe campimul iffhepermit is forces hundred dollars (5100)
or les]
I certify that in the performance of the work for which this permit is issued, l shall
not employ any Person in my mu or so as In become subject to the Workers
Compenatimlawsof California. Date
WATER HEATER W/VENT/ELECTR
PAID
Date Receipt#
WATER SYSTEM/IREATING
Applicant
NOTICE TO APPLICANT: If, after making this Cenifiese of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
become subject to the Workers Campensadm provision of the IaMr Cede. you most
forthwith comply with such provisions or this permit shell be deemed mvoked.
BUILDING FEE ,
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
TOTAL:
ELECTRIC FEE
1 hereby affirm our them is a corunmtion lending agency for the perfmmance of
the work far which this permit is issued (Sec. 3097, Civ. CJ
'"""•T %t'`%+:-„ -
QTYi „ny;'„ MECHANICAL PER FEE
PLUMBING FEE
Lenders Nene
Lenders Address
I certify chat 1 have reed this application and erste Nat the above inf oro tiro is
arrest. I agree to comply with ell city end caunry ordNancu and su¢ laws relating m
PERMIT ISSUANCE
MECHANICAL FEE
-
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
building construction, and hereby anchorite repreentatives ofthis city to enter upon the
above-mentioned property for inspection purposes.
AIR HANDLING UNIT (TO 10,000 CFM)
(We7 agree eve, indemnify and keep harmless the City of Cupertino against
liabilitiee.jud ts,consmdexpmxv.which may in any way etc agwrseaid Ciry
AIR HANDLING UNIT (OVER 10,1100 CFM)
ce of granting of IS permit.
EXf1AUST HOOD (W/DUCT)
PAID
Signemrco App..V muraemr Date ,
HEATING UNIT(TO IM." BTU)AID)
HAZARDOUS MATERIALS DISCLOSURE
Dau Receipt#
HEATING UNIT (OV ER 100,000 BT
TOTAL:
Will the applicant or future building amupons corm or handlehazerdous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and de, Health and Safety
VENTILATION PAN (SINGLE RES
GMC. Section 25532(0)7
❑ Yes ❑ No
Will thenpplicmmrfutumbuildingaucupant useequipmentmdeviceswhichemit
air contaminants as defined by the Bay Ama Air Quality Mangement
BOILER - COMP (3HP OR 100,(1(10
BOILER-COME(OVER IM."Bmrso
ISSUA�CFgAU EFahk
Lqq 6477azardous
APR 25
NEW RESIDENTIAL MECH.
❑ Ye ❑ No
1994
Ip 1 have read the hezndom materiels mquiremena under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533 and 25534, 1 undersand that
Cil Y Ur Muir
IT the building does nut currently have a tenant Nat it is my responsibiliryro notify the
occupant of the requir ments which must be met Prior to issuance of a Certificate of
Occupancy.
ISSUED BY:
Owner or authorized agent Date
TOTAL:
oI-RCE