26104 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUILDNG-E AL PERMIT NO.
CITY OF CUPEAPPLICATION/PERMIT PLUMBING-MECHANICAL.
26104
BUILDING DIVISSIOIO NO N BUILDING PROJECT[DEN'fIFICA DON
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
Q UNIT# LOT ��
OWNERS MG PHONE: COM CTOR'S NAME: _ I LIC
IyL�yNyl(le N/C CONTROL
16A IUEECl/LNGINEER: LIC NO: ADI SS ❑
_ Jr3v-�2 ple,
corrrncr: PHONE: T ELE RIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ E:]LICENSED CONTRACTOR'S DECLARATION APPLIANCESRESIDENTIALnw% I hereby affirm that Iran licenced under provisionxol'Chapmr9(commencing with JOB DESC/Rr I�Pf10N
POO Senium]gp)ofDivi'nJof the Business and Professions Cale.and my li«nse is in PANELS
ad U Tau force ff
pQZln Lianor Ira.# UP'10200 AMPS
m vdh Uam Convenor 201-1000 AMPS
ZO ,z ARCHI'IEC`PSDECLARATION OVER 1ggAMPS SQ FT.FLOOR AREA $/SQ FT.
Oz n
I understand my p n shall be used as public records.
SIGNS ELECTRICAL
Lima"d Nefessirml
�yp6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
xI hereby affirm that 1 not exempt from the Contractors Licence Law for the
mJ�Om¢ following nenow.(Section 7031.5.Btaransand Ismfevimms Code:Any citymcounty/ M�TE O L T R
,a. which¢quires a permit to comsven,stmt,imm e,demolish,or repair any stmnum
�n}n pnorto its issuance,also requires the aMlicant for.uch permitto file a signed statement POWER'UEVICESI—. .T. L✓
.'<O that he is licensed pursuant to Ne provisions of the Contractor's License Law(CWptm
ay y� 9(mmmencing with Scetion]000)of Division 3nf the Business and Professions Cale) SWIMMING POOI!ELE IC
kOpy ,. VALUATION
y)_y or that he is cxempuherefmm and the basis for thcallegcd exemption.Anyviolationof
tZQ Section 7031.5 by any applicant for a permit subjects to,applicant e applicano a civil penalty of OUTLETS-S
220 not more than five hundred dollars($500).
e'F-o ❑ 1,asnwneroftheproperty,ormyemployeeswithwagcsas Neirsolecompcnsmion,� �I FT. .I STORIES TYPE CONSTRUCTION
wilt dothc work,and the stmnure is not intended croffcmd foreale(Sm.9(14q Business
and Profeslons Gde:The Contructor's License Law docs not apply to an owner of
propenywho buildsorimpmves therron,and whodoessuch work hince for Waugh his
owncroplayres.wasided thatnuch improvements we not himadedor offered forsale.If, OCC.GROUP RES.UNITS
however,the huildingor improvement is sold within one yearofcnmpletion,rhe owner- Try!AL
builder will have the burden of proving that redid not builder improve for purpose of
sole.).
❑ I,aaownerofthepropeny.amexclusivelyconoactingwithlicenudconv ionto QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
omsOua the meject(Sec.7014,Business and Profusions Code:)The Cmentemr's PERMIT ISSUANCE
Dow,e Lawdne.not op ply in antwimml opwy who baildsor impowcsthereon.and
whmenntnetsfor such projects vithicontmemr(s)licensed pursuvit to the Contracmrs ALTER (Eq)
Liana Law. FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this mason BACK FLOW PROTECT.DEVICE. OUTSIDE FEES-
SAN]TARY
EESSANI'T'ARY YN
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROORAREA,COND. SCHOOLTAX Y N
❑ Thereby affirm that l have a ceniEcam n
ofconseno self-insum,oracenificamof ITXTURES-PER TRAP RECLIPI'N
Workcnm
'Comnsatiun Insurance nrncertified copy thercmf(Sec.3800,Lab CJ which PARK PEE YN
Policrs all employee' A. INC.4 OUTLETS s under Nis permit. GAS-ESYSTEM-I RECEIPT p
y# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
Ed Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEF.
CERTIFICAT'Ii OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This uctionnminot he complecd if the permit is for one hundrrd dollars($100) SEWER-SANITARY-STORM EA.20011'. ENERGY FEh
nr less.)
I certify that in the performance ofthe work for which this permit is issued,F shall WATER HEATER W/VENT/ELECTR
not employ any person in my manner
sat became as to subject to the Workers' PAID
O Z Campensations
l.awof Califumia. [)ate WATER SYSTEM/1REATING Dam RecciptN
Applicant
NOTICE TO APPLICANT:If.after makingthis Cenificatcof EncmSQ.ption, ..should NEW RESIDENTIAL PLMB,
F � become subjecto the Worker's Compensation provisions of of the labor Code,you must TOTAL:
iz forthwith comply with such provisions or this permit shall he deemed revoked. ` �� BUILDING IIiE
1 D CONSTRUCTION LENDING AGENCY SEISMIC FEE
z Ihereby affirn that then is a consometion lending agency for the performance of
L) Q the work for which this permit is issued(Su.3097.Civ.CJ T ELECTRIC FEE
Lenders Name
O L) Lenders Address QTY. MECHANICAL PERMIT FEE
PLUMBING IEE
V I mirofY that 1 have read this application and state that the above information is
correct lagreetecomply withallcily.nde....ycrdinancaandnamlawsrclmingto PERMIT ISSUANCE, MECHANICAL FEF,
F-' to building construction,and hereby aohonze representatives ofthis city acclamation the
U Z above-mentioned progeny for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree to save,indemnify and keep harmless the City of Cupertino against
.r habililms,judgmems.costs sndexpcots$which may in any way acerae against said City AIR HANDLING UNIT(TO 10,00)CFM)
in conscquen gof thispennit.
IR HANDLING UNIT(OVER 10.000CFM)
Signsol'ApritardVoin;lgir, I m EXHAUST HOOD(W/DUCG
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(1`0 100,000 BTU) Dam Receipt Or
Will the applicant or future building occupant store or handlehazallous material HEATING UNIT(OVER 100.000 BTU) tD
s final by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
C ,Section 25532(a)?
E)Yes ❑No VENTILATION FAN(SINGLE RPSID)
BOILER-COMP DHP OR 100,000 BTU) ISSUANCE DATE
Will the acomentorfumrc defined
by the Bay Area Air Quality
s which Management
it p
Diwim us air contaminants m defined by the Bay Area Air Qunlity Management BOILER-COMP(OVER 100,000 BTU) #'�
t District?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
1 have mad the hazardous mumrials requirements Once,Chapter 6.95 of the WAR - 7 1994
California I leahh&Safety Code,Sections 25505.25533 and 25534. I command that
if the budding does not currently have a tenant,that it is my mspomibirty to notify the (illy UC IaUY
occupant n(the oc,imari ms which most biss
IN,met prior to uance of a Certificate of Cn 111'
oacavaney.
Owner or ooh...ed.,cat Dam TOTAL: ISSUED BY:
OFFICE