26623 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPESION UUILUNul- '-' PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT II)NN'1'IN'ICA'f1ON 26623
BUILDING ADDRESS: SANITARY NO. APPIJCATIONSUBMITALDAIE
LOT#
OWNL E PHONE: to OR'S A LIC NO:
N/C CONTROL#
CHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUM1jr MECH
PERMIT ISSUANCE �. " ISY
1
LICENSED CONTRACTOR'S OECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
f py�Z Thereby of
3 ofth Bu underdd Professions
Code,
my Re ing wiN
Per100 Section e and o f Division J of the Business and Professions Code,end my littme is in PANELS
< Licfailense
Tome and effect. 70
/��
pa„ZW License Clans Lic.p IIPTO 200 AMPS PIPI
w a y Dam Connector 201-1000 AMPS Y�s�V/
Z Olr'n Z ARCHITECTS DECLARATION OVER I A .SQ.FT.FLOOR 3/SQ.IT.
tiI undemwnd mY plum shall h used u public records. IG S L ��
a�d .4 Licensed Professional
L pB�tr�a OWNER-BUILDER DECLARATION IR /MISC.
KOyU 1 hereby affirm that I on exempt fmm the Convactots License Law for the
413 ti rn following mason.(Section 7031.5,Business and Professions Codi.Any dry arwwry OR POLE INST.
which requires a permit to wnxlmcL wind,improve.demolish,or repair any structure
Y7 prior to its issuance,also requires the applicant for such person w file a signed statement POWER DEVICES
pj a��pm Not he is licensed pursuant to the provisions of the Contractors License law(Chapter
0- .LL 9(commencing with Second? 00)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
y�Lat or that he is exempt therefrom and fie basis for the allegrdexerrption.Anyvialadon of 4urnms.SWITCHES-FIXTURES 1
Z G Section 7031.5 by any applicam for a Permit subjects the applicant w a civil penalty of
K pnot mom then five hundred dollars(SSW). NEW RESIDENTIAL ELECfR 5 .PT.
❑ I,ssownera(Ihe proparty,ormyemployeeswithwegcsasthciraolecompensadon, Q STORI TYPECONSTRUCTION
a 3°-° and Professions
C d e no Contractor's
Lawred s not apply
to an owner of 7-
property whobu Ids viimprovesth improandwhodosmelt work oreefortlwughhie
own emplOyees,pmvidetl lhmnuchimprovememaere notimmndcdoraffered Tarsale.if, OCC.GROUP RES.UNITS
however,the building or improvement issold within one year ofcomplesdon,the owns- .ro
builder will have the burden of proving that he did not build or improve for propose of
sale.).
❑ I,mowner ofthe property,soneaclusively contracting witlicensedcontmewm to QTY. PLUMBING PERMIT FLOOD ZONE APN
consmmt the pmjmt(Ser.7044,Elemeu and Professions Code)The Conoecmre PERMIT ISSUANCE
License Law domard apply tounownerefpmpeny whobuildsorimprovesthereon,and
who con Insets for such projects with a commctons)licensed pre suenno the Conumhor's
License Law. ALTER DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 em exempt undo Sec. ,B&P C far this¢neon BACK FLOW PROTECT.DEVICE ID
SANITARY Y N
Owner Date DRAINS-FLOORROOF, CONDRECE:IPTp
. , , .
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ I harehyaRmn that i have acrnificau ofconsent to self-int mu anificenof RECEIPT
g
Lnrkem'Compensation Insurance or acenipederty thereof(See.3800,Lid,C.)which FIXTURES-PER TRAP �� PARK FEE Y N
en all employma under this permit GAg-EA.SYSTEM-I INC.d OUTLETS RECBI #
Policy p BUI I VI ON FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCIMCK FE 2 O
❑ CctTifted copy is hereby fumished.
❑ Cent copy is fled with the city inspeedon division. f GREASE/INDUSGRADING FFfz Vr�
CERTIFICATE OF EXEMPTION FROM WORKERS' G SIE SOILS FEE
COMPENSATION INSURANCE mFir assaaa
(Uds accident need not be completed ifthe permit is forom htmdroldollarsSIM) EWERSA 1 T EVER
or less.)
I unify Net in the perlbmonca of the work for which than.permit is issue,l shall WATF.RHEATER WNENT
not employ any prrcon in any marma so v to become subject to the Worker% �,G PAID
v
Compeatian Lawsof CWiforol.. Due #Nap SYS Dow e
Is
0 z Applicant
0 NOTICETOAPPLICANT:lf,Wwrmakingthis Cenifiwteof E.emption,youshoW NEWRESIDENTIALPLMB. SQ.FT. TOTAL:
V] become subject to the Worker's Compensation provisions of the Labor Code,you most
,
a forthwith comply with such provisions or this permit shall No deemed revoked. I BUILDING FEE ra
0.Wi Q CONSTRUCTION LENDING AGENCY SEISMIC FEC
V z l hereby afftmh that Mete is a covwedon lending agency for the perfomonce of T r ECIRIC FE
0 the work for which this permit is issued(Sec. 097
3 ,Civ.C.)
L etWer's Name
Lender's Address QTY. MECHANICALPERM"I FEE PLUMBING FIDE `
0 V I eertify Nat I have read this application and.ate the the all infomwtion Ts MECHANICAL FEE
ICI correct.l agree to comply with all city and county ordinances and stew laws relating w PERMIT ISSUANCE
�^ buildingeons.cdon.mdhaebyauNodnmpe mdvesofNisciry wenterupon Oe CONSTRUCTION TAX
L) z shove-mentioned por'ny for inspection purposes. ALTER OR ADD TO MECH.
Wed agree to rove.indemnify ad trap hnmlw IM Ciry f Cyupeninn gainsI
liabilities,judgments,cosw and expenses which MY in my c ` genet 'ty ALR HANDLING UNIT TO I O.000 CFM)
conxqurnce ting of Nis permit. \�sV�,
AIR HANDLIG UNIT(OVER 10.000 CFM)
Signa w Applicant m EXHAUST HOOD(W/DUCO PAID 1
HAZARDOU M TERIALS DISCLOSURE HEADING UNIT(TO 100,000 BTU) Data Receipt#
ill the applicant m fmwe, Id, g acmiant ewe as badle humorous maedtl TOT
as defined by the Cupertino Muniei We,Chapter 9.12,and to Health and Safety HEATING"IT(OVER 100.000 BTU)
Cade,Section 25532(.). VENTILATION FAN(SINGLE REBID) anr►�
11 Yes 1:1 No
ISSUANCE DATE
Will theapplicamrnfuturebuildingmcupam useeyuipmentordeviceswhichemit BOILER-COMP DHP OR 100,000 BTU) II�7�
hurricane air comammu
ints defined rta by the Bay AAir Quality Management BOILER-COMP(OVER UK,000BTU) PAID
6
District?
❑Year ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have read the haarand
heus mals requirements ander Chapter 6.95 of the AUG 151994
California Houhh&Safety Cade,Seellons 25505.2553]and 25534.1 understood that
if the building does nm currently have a tenant,that it is my xsponsibility to notify the G� Y
occupant of the requirements which must he met prior w issuance of a Certificate of Ur (curt (IV
Occupancy.
Owner or auNoneed agent Doe TOT ISS ED BY
OFFFCE-