26189 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
MY OF CUPERTINO PLUMBING-MECHANICAL PERMITNO.
TION/PERMIT -26189
BUILDING DIVISION APPLICA
NIIILISING PH(IJEC'IIDN:N'HFICATION
BUILDING ADDRESS: j� SANITARY NO. APPLICAATIONNSSUBMII'TTTAL DATE
ttUNIT# LOT# � /�_
OWN N � / PHONE: CONT C[OR'S[J LIC NO:- UL l
sasi_a 1/_ Y airvit Zt Z .LOAD /`+g`J\ NIC CONTROLM
CHITECOENENEER: ��.lM1 LIC NO: I ADDRESS.
ONPACI': PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PL MB MECH
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
QyZ I herebyalfrrm that l con licensed under provisioruafChapter9(commencingwith TOB DESCRIPTION
{�00C Section 10 ly f Division]of the Business end Profusions Code,and my license is in PANELS ' '�
��U full force:..ffcct. h Sr_
FZw License Clas LIC.# UP TO 200 AMPS "Nr—
vs,6,y Data Contractor 301-1000 AMPS SQ.FT.FLOOR AREA S/SQ.Ff.
3:On z' ARCHITECTS DECLARATION OVER 1000 AMPS
� pp 1 undeemnd my plans shell be used w public records.
rZn[–u3 SIGNS ELECTRICAL
Q j Licensed professional
�w< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
RXX'O y U 1 hereby affirm that I am exempt from the Conwcsa's License law for Ne
W 3 LL y following ecawn.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
LL' which require a pemdno construct,Wier,improve,demolish,w repair any evucwre
prior to its issuance.also requires the applicant for such permit to file o signed emtwnans POWER DEVICES
W C 0¢O thm he is license punu m so sae provision of the Comvewors Lt..law(Clmpser, SWIMMING POOL ELECTRIC VALUATION
,,Mn9(commencing with Section 7000)of Division 3 of me Business and Professiom Code)
0y or he isexempt therefrom and the basis for allege exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
F 7.a Section 7031.5 by any applicant for a permit subjmss she applicant to a civil penalq of
t dmn five hundred dollars(S500). NEW RFSIDENTIALELECIRFT
—SQ. . STORIES TYPECONSTRUCTION
C p ownerofthcpmpeny.ormyemploycaswithwagent eirwlecomp radon,
y,3_ will Jothewok,and the ssrocmreis not intended proffered fa sale(Sce.7044,Business
and Professions Cade:The Convectors License law does not apply in an owner of
pmpeny whobuildsorimprovestherwn,and whodeessuch work himwlforduoughhie
employeu,provide that such impowemernnam not imendedmaffered hand,If,
OCC.GROUP RES.UNITS
however,the building or improvement is sold within one yew of completion,the owner.
TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
ss1e')' QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ hnownerofthepropeny.em exdoaivelycomnning with licensed convacsorsso
construct the project(Sec.7044,Business and Profusions Codc:)Th.Contactor" PERMIT ISSUANCE.
License lawdocsnotapplym an womof property whobuildsor improvesibroorn,and
whocommursfasuch projects with acontrmaKs)licensed pursuant toshe Convectors ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
License Law.
❑ 1 em exempt under Sa. ,B&P C for this meson BACK FLOW PROTECT.DEVICE UTSID
SANITARY Y N
Owner Date— pRA1N5-FLOORRECEIPT
.ROOF.AREA.COND.�+– WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Ihereby affirm that l have a ccnificam ofcomenno self-insum,or a certificate of FIXTURES-PER TRAP RECEIPT
Waken'Compensation Insurance or a certified copy thereof(Sec.380,Lab C.)which PARK PEE Y N
ars all employee's under this Permit. GAS-FA.SYSTEM-1 INCA 0I1TLE1'S DIVISION
Policy N BUILDING DIVISION FEES
Company GAS-EA,SYSTEM-OVER4(CA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASFANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION PROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is forone hundred dollars DI00) SEWER-SANITARY-STORM P.A.200FF. ENERGY FEE
or less)
I certify that in the perfomince of the work for which this permit is issued,Ishalt WATER HEATER W/VENT/ELECfR
not employ any Person in any interior w as to become subject to the Workers' PAID
Cwnpensatim Lowsof Celifomia. Data WATER SYSTEMITREATING Data Receipt#
O 7-+ Applicant
C NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLACE, SQ.IT, TOTAL:
F� (z) hecomesubject to the Worker's Compensation nowhi mo0fdMLabor Cnill must
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
5 CONSTRUCTION LENDING AGENCY SEISMIC FEE
zhereby affirm that there is a construction lending agency for the performance of ELECTRIC FEE
U O the work for which this Permit is issued(Sec.3097.Civ.C)
O �r Lender's Name PLUMBING FEE
t" lenders Address QTY. MECHANICAL PERMIT FEE
U I cenify that I he.reed this application and state that the above information is MECHANICAL FEE
contact.I agree 0 comply with all city and county ordinances and state laws relating m PERMIT ISSUANCE
f–' building construction,and hereby authorize expreserintivesofthiscity to enter upon the CONSTRUCTION TAX
U Z above-menti ed property for inspection purposes. ALTER OR ADD TO MECH.
(We) te save,indemnify and kap harmless she City of Cupertino against
liabi�aj nandenpemes which may in soy way memo against said City AIR HANDLING UNIT(TO IB.000 CFM)
in come h granting u hispermit. AIR HANDLING UNIT(OVER I CFM)
ApplicanVConrcactnr One EXHA CH PAID
HAZARDOUS MATERIALS DISCLOSURE HCATIN UNIT(TO IlI0,IX10 BTU) Data Receipt If
Will the applicant or future building occupant store or handle humorous material HEATING NIT(OVER 101"fkkLDjNTOT
as defined by the Cupertino Municipal Cale,Chapter 9.12,end the Health and Safety
Code,Section 25532(87 VENI'ILA"H NPAN(SINGLE RFS
❑Yes ❑No
ISSUANCE DATE
Will the applicantorfmure buildingoacuprausawuipmentrdevices whichemh BOILER-CO P(JHP OR W, TU)
�hwwdoue air commissions as defined by the Bay Area Air Gushy Management BOILER-COM OVER 1 TU) 4'i
District pp
❑Yes ❑No NL•W RESIDENTIA MEC11. .IT.
1 have read she haoudous mammals requirements under Chapter 6.95 of the ��� 1994
California Hetlth&Safety Code,Sections 25505,25537 end 35534. 1 undersand Net
Era,building it.. I currently haveatenws,that it is my resporidbilqu,notify the
o c,crat of the re uiremems which must M met poor to issuance of a Certificate of Cll! Ur-
Occupmrcy. VUf\ \l/gei r 1
Y
op
Ovowwwah osd agent Dam TOTAL: ISSUED BY:
OFFICE