26679 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUILUING-KLEUMICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 26679
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITTALDATE
V � Q a UNIT# IAT# 1�
OWNERS NAME: PHO fi: C OR'SN LIC NO' l 1.
D E _ Qf rdk NIC CONTROL If
ARCl..TEC I[ENGINEFA: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. r ftC%E.'IC PERMIT FEE
BLDG ELECT PLUMB MEC!{
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
ZWz I hereby affiem that l amlicensed under provisions,'Chapter9(commencing with LOB DESCRIPTION
VOO Section 7000)of Division 3 ofthe Business and Professions Cade.and my license is in PANELSK V full force and off«t. /+
pZW License Class Lie,N UP TO 2M AMPS r`
vsjy Dae Contractor 201-I"AMPS {_
ZOr` KARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AR IA $/SQ.FT.
OZ-0 I understand my plans shell be used ss public records.
SIGNS ELECTRICAL
Q Licensed Professional p
S n< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. L E n A
P�OiF I hereby n.(Se the 1 oro exempt from the Contractors o License Lew for the _-x 1' u
lal3Oya whichfollowrequires BPermit 10 T03L5,Business and Professionsh,orraAny airm or county TEMP,METER OR POLE INST.
ce J which requires a permit re conswa,aper,improve,demolish,or e v aig any stremma
5 }� pdnrmiricensed ,also ret to the
Nevisiosofthe Co Permit ftleasigna statement POWER DEVICES
Q O
that he is licensed pursuant m the provisions of the Contractor's License Lew(Chapter
C.qo S'L 9(commencing with Section'7000)of Division 3 ofthe Business and Professions Cade) SWIMMING POOL ELECTRIC DATE
DATION
od M_ or that he is exempuhetefrom and the basis for the alleged exemption.Any violation of OUTLET'S-SWITCHES-FIXTURES
F RSQ Search 0031.5 by any applicant for a permit subjects the applicant m a civil penalty of
< not more than five handed do11as($5DB. NEW RFSIDEN77AL ELECfR 5 Q.K ❑ I,asownerofthepmpeny,ormyemployeeswithwagesmtheirsolecompcnsazion, Q STORIES TYPE CONSTRUCTION
y _ willdothework,and the structure isnot intended moffered forsale(Sec.7t ,Business
and Professions Ccde:The Connector's License Law does not apply to an owner of
pmpeny who trades m i mproves hereon,and who does such work hi msel f or hmogh Ida
hoemployecs.provideJ that suchimprovememaart not intendedomffeed forsale.If, CZCGROUP RES.UNIT'S
wever,the buildingor improvement is sold within one year ofcompletion,themmar- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
ari
❑ I,asownerofthe Wt)pny,amexclusivelycontractingwithlicensedconmtomm QTY. PLUMBING PERMIT FEE FLOODZONE APN
construct the project(Sec.9014,Business and Professions Code:)The Contramols
License Law does not apply to on owner ofrommy who builds or improves theme.and "a" PERMIT ISSUANCE
who contracts mrsuch projects with econvacmds)licensed parnmenuo the Contractor's ALTER EA FEE SUMMARY
License Law. 1 )
❑ lam exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE GO TSID s FEES
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA,CONO. RECEIPTp
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ Thereby affum then Mveacenifi<ne of canscm meal(-insue,on ttnifiwte of FIXTURES-PER TRAP RECEIPT#
Warken'Compeasaion Insurance or n certified ropyheeof(Sana.3800,Lab C.)whichPARK FEE Y N
covers all employaser under this pemtit GAS-FA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-0VER 41EA) PLANCHECK ME
❑ Certifiedcopy is hemby famished.
❑ Certified copy is filed with the city inspection division. GREASEIMDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(his section need not lx completed ifNe permit is Intone hundred dollars P$100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I comfy that in he pedormanceof the work far which his permit is issued.I shall WATER HEATER WNENT/ELECIR
not employ any person in any m so as to Become subject m the Workers' PAID
Contpensation Lowsof Califomia Date WATF.RSYSTF.MMEATING Dm ReceiptM
O Z Applicant e
z R NOTICE TO APPLICANT.If,after making his Cenificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
to become subject to he Workers Compensation provisions of the Labor Code,you must
P
-� foMwith comply with such provisions or,this permit shall M deemed revoked. BUILDING HE
y (� CONSTRUCTION LENDING AGENCY SEISMIC FEE
Uz 1 hereby affirm that there is a construction tending agency for he perfonnence of
O the work for which this pemtit is issued(Sec.3097,Civ.C.) ELECTRIC FEE
Lender's Name
0 U Lender's AdPLUMBING FP.E dress QTY. MECHANICAL PERMIT FEE "s'V 1 certify that I have reed this application and We that the above information is
cotter.lagreemcomply wih ell city end county oMinanttsand state laws rcletingm PERMIT ISSUANCE MECHANICAL FEE
In M1uildingconsmuction,and hereby amhnrim repmsenwtivesofhis city m emerupon he
U 7 ahnve-mentioned Property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Iiabilities,judgmrts.custs andexpenses which may inany way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
in roTequence of he gntigoispeeh01
_ `J L Q AIR HANDLNG UNIT(OVER 10.000 CFM)
Signature of Applicant/Commucar Date I EXHAUST HOOD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,00011TO) Date Receipt If
Will theallicam of future building occupant sem or handle hmallous nummad "EATING UNIT(OVER 100,000 BTU) TOTAL:
as defined By the Cupcnian Municipal Code,Chapter 9.12,and the Health and Safety
Coda,Section 25532(a)T
11 Yes 13 No VENTILATION FAN(SINGLE RFSID)
ISSUANCE DATE
Will he applicant(ir futurebuiMingoccupant use equipmentordeviaswhiehemit BOILER-COMP(3HP OR 100,(100 BTU)
hasrrdaus air comamimants u defined by the Bey Ara Air Quality Management BOILER-COMP(OVF.R IW,000 BTU) "� ID
District?
❑Yea ❑No NEW RESIDENTIAL MECH. SQ.FT. JUL n
I have mad he haeoudous materials paphi ments under Chapter 6.95 of the 1994 \�/�/�//
Californiam
ia l health&Surely Code,Sections 25505,25533 and 25534. 1 dersmnd that a V
if he building does not currently have a arae,hat it is my responsibility to notify the CffY Ur ante
occupant of he re'amnsems which mune be met prior ret issuance of a Cenific us of %I Bill,.;Occupancy.
Owner or aahmised agent Data TOTAL: ISSUED BY:
OFFICE