26052 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILD I G-e RIUAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 26052
BUILDING PR(3JEC1'IUENTIFICATION
BUILDIN��ESS: Hol anaic tv` . UNIT# LOT# SANITARY NO. APPLIGTION SUBMITTAL DATE
OWN AME: PHO CONTRACTOR'S NAME: LIC NO:
G 1r` 6— 6 NIC CONTROL#
RCf11TECT/ENGINEB. V/C LIC NO: ADDRESS '_J ❑
Y
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
' B ELECTPLUMB MECH
PERMIT ISSUANCE9 1:1 El
LICENSED CONTRnderim )DECLARATION pppL1ANCFS-RF.SIDFMIAL JOB DySC�ION
p00 Ihcreby.Mi met,umlice Businderpmvisionsons,Coaeacommencing with
Y100 Section]000)of Division3of the Business end Rofnaiom Cade,end my license it in ppNF.LS e'^V
taz_F. full
tura and arras.
6Fz� Licenu Class Lic.p UP T0200AMPS
r 4 Dam Convaaor �•� 201-1000 AMPS
Fp-5a Yf 5 Irl'.FLOOR AREA E/SQ.FT.
ZOZ-O Iunerstan my Plansshall)be uand.public rsord U OVE0.ELL AMPS Q'
rn SIGNS ELECTRICAL
Q
Licensed Professional
a'6
OWNER-BUILDER
pt froDECLARATION Contra SPECIAL CIRNIT/h1ISC.
°�OyU I hereby affirran(Se that 1.m exempt from me Contractor's License Lew for the
1+130ti
following (Section]031.5,t,Business and Professions capoli Co de:Any city orcountyT13MP.METER OR POPE INST.
E'.y� poor
Leapplicitforsuh permit to
ore a air siganystmmurt
C,<f priori.slissuance,palsumtto the prvisionsofthe Cormomiuo filLicense
Law
POWER DEVICES
yl C pK mm he is licensed pumm�no the)of Division
of the the u Business
Licenu Law(CTopter
a eLL 9(commencing with Satian]IXp)of Division 3.f the Businessmd Rofessi.m Code) SWIMMING POOL ELECTRIC / VALUATION
Nor, or that he is exempt therefrom and the basis for the alleged exemption.My violation of `-
Section 7031.56 an applicant for OUTLETS-SWITCHES-FIXTURES V/
y y pp permit subjects the applicant to a civil penalty of
��a not(],mown rofthed rgydo]lam(5empl r
FG NEW RESIDIiMT1AL EL[CfR _SQ.FT. STORIES TYPE CONSTRUCTION
aC ❑ L asowok ufmce smctY•ofmyemployaswiNwagu...]a S lecompensiness
32 wit domeximis Cooandk: truCommnt'.LicnseLa do es net apply
TOim Business /
snit Professions Cod,:The improve,
tmcma.License Lew does not apply to an owner of
ownenyl hebuildsodmpr.vathereom.ndwhodwssuchw.h hinnel(wthrough his
employees,# or improvement
is mmenthin ne earoedw.ffemd the own r- DCC.GROUP RES.UNITS
builds, ill hpvbuilding thorrden of proem ishat he id not build or mprove onJ purpose f TOTAL:
owner-
builds,will I�ve the burden of proving that he did not build w improve for purpose of
le.).
❑ I,esowner.fdm propeny,emexdusivelyconvacting wimlicenseA<.n.acmla rn QTY. PLUMBING PERMIT FEE PL00 ZONE APN
<omwct the projst Wsec.7004,Badness sad Professions Code:)The Contractor's, it PERMIT ISSUANCE
Licenser the pitWI,
tom.wnerness mnywhosions ode:) vo thereomand
whocenuaco for such projeam with a commetond licensed pursuant Commences ALTER-DRAIN&VENT-WATER(FA) FEE SUMMARY
License Law.
❑ 1 sin exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEt9CEr. II TAR 1 Y ES N
Owner Dom - .a m RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR.ROOF,AREA,COND. - SCH YN
C3 hereby affirm that l have a cenificam ofmncan
no calf insure,ora cenificim of FIXTURPS-PER TRAP 1 ' RECEIPT#
Workers'C=NnmtimlmummcoramnifiMmpythemof(Ss.38W.UbCJ which v PARK
ML 0 1
N
covenall employYECFPp
GAS-EA.SYSTEM-I INC. OUTLET /
Policy#- - - %f 7S�J✓CJ^7 - p BUILDI GDIVISION FEES
Companyy�,x,��'a�Ir GAS-EA.SYSTEM-OVER 4i4FFP
❑ CenifiW copy rs hereby fumiehed.
Certified copy is fled with the city inspection division. GREASFpNDUSTRL WASTE INTERCEPTOR GRADINGFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This union need not b,completed ifthe permit is fwonchundud dollvs(SIM) SEWER-SANITARY-STORM EA.20017, ENERGY FEE
or less.)
I certify thus in the pmf or mwhichmispennitc.n.. ,Imall WATER HEATER W/VENT/ELECIR
am employ mya r a o become subj a ars PAID
Compensation Ia a Alo Date WATER SYSTEM/IRFATING Data Receipt If
O z Applicmt
NOTICETOAPPLI 1':ILtifermak ng is nifcine of Exemption.you should NEWRHSIDENTIALPLMB. SQ.FT. T
rA bec.mesubject to the Workers Comperom apt isionsofthe Labor Code,yoummt
ai formwith comply with such provisinns or this pttmit shall be deemed revoked. BUILDING FEE
W 2 CONSTRUCTION LENDING AGENCY SEISMIC FEE
tI herebyaffrm thin then isaconstruction lendingagency for theperformar of
L) me work for which this Permit is bound(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
p Lender`s Name
� U-' Lon ex Address QTY, MECHANICAL PERMIT FEE PLUMBING FEE
LU17 1 certify that I have reed this application and state chat the above information is MECHANICAL FEE
RCs. )agree to comply wim all city and coumy.rdinencm and ntmelnwe relining to PERMITISSUANCE
F' building construction,and hereby mithmimrepretiommivesof this city to inter upon the CONSTRUCTION TAX
U z above-mentioned property for inspection tourist ALTER OR ADD TO MECH.
(We)ugrce indemnify unit keep harmless the City o'Cupcnino against
lmbilifiea,j gmntamstsandex which mayinanyw.ymorueagninstaai City AIR HANDLING UNIT(TO TO."CFM)
c.nseq a N granting. this it.
AIR HANDLING UNIT(OVER 10,000 CFM)
Simat fA licant/Cmtm m E%HAUST FIOOD(W/DUCT) PAID
13AZARD MA RIMS DISCLOSURE
HEATING UNIT(TO Hal"BTU) Data Receipt If
Will the the Cope or furore building occude,C a p some o,handle Health a d Safer l
m defined by the Cupertino Municipal Cork,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) O
Code,Section El 25532(n)? VENTILATION FAN(SINGLE RESID)
❑Yea ❑No
Will the npplicanswfummbuildingscupmtuuryuipmentordevicmwhichwnit
BOILER-COMP QHP OR IOLDOO BTU) ISSUANCE DATE
hmrdous air contammo
ints defined by the Bay Am Air Quality Management BOILER-COMP(OVER 100,000 BTU)
a
pnriCl?
❑Yea ❑No NEW RESIDENTIAL MECH. SQ.FT. R1 p D
1 have read the hersrd.m ma uiremenm under Chapter 6.95 of the Y- Y9
1buddingil
mia liwlth Safe ode,Sec on.25 5,25533and25534, iunderstand thin ��nm n0y hev amnan that it is my responsibility to notify the tn3 1
snt of t td whit ust et prior b iguana of n eniliam /sVp Y. 4 VII 11�'
Ownerm. rim agent ate TOTAL: ISSUEDB Uf
OFFICE