26112 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOILUI .-ELL 'IRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL A /�
BUILDING.PROJECT IDENTIFICATION L L
BUILDING ADDRESS: SANITARY NO. JAM�JCA'nOlq SUBMITTAL DATE
/I N UNIT as LOT is JisA
0 NDE. FI C gCTOR'S NAME: LIC NO: - l•
S !/ I n .� S NfC CONTROL p
RC 11 Cf INEER: LIC NO: ADDRESS' �./S^, /� Q r� ❑
ONTACT: PHONE QTY. ELECTRIC PERMIT PEP, BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
0`4z I hereby affirm that l am licensed under pmvisinnsofChapter9(emnmencingwith
�it00Section]000)of Division 3of the Business and Professions Code,and my license is in PANPI9
full force antl a t. '7-5- 1
QVV ��� �1 / UPT02MAMP5
Zan Licen- less LIC.#
y=y Date Conua�m,(.ta 201-10)0 AMPS
F-y Z ARCHITECTS DECLARATION . � SQ.FT.FLOOR AREA E/SQ.FT.
Z O m OVER 1000 AMPS
O Z—O I understand my plans shall be used v public records.
rn Pl SIGNS ELECTRICAL
4 i'N Licensed Professional /
6 uu�� OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. 1
OyF 1 hereby affirm that 1 am exempt Tom the Courtractor'sCo License Law for the
3 of rQn following teres..(Section manstr Business and Professions Cade:My city or county TEMP.METER OR POLE INST. _ [ h
f!�.f5 Q J which requires r permit re coaswcL alcor,improve,demolish,ore a sir any amteure f�
Mo that heor to I,fiectancqulsounnires the
rociti ari for ch Copenniuo rilLicense
La statement POWER DEVICES )
"yj C D O that he is licensed pursuwt m the)of
isiotss of the Comncness License esw ns Ceder
a4 z 9(commewin with Section]000)ofDivision]ofthe Business and Professions Cade SWIMMING POOL ELECTRIC
xoy, (commencing ) A UATITr�
Wim Seetioor dual heis 1.5 by my
mnt f the Permit subjects
thedexemard to civiny l
of OUTLETS-SWITCHES-FIXTURES
z Q Section than by any applicant cant fore permit xubjecU the applicant to r civil penalty of
not mom than five hundred dallna .m C1I,usownttoflhepropeny.ormyempyemployceswith wagnaatheiraolecompensation, NEW RESIDENTIAL ELECIit _EQ.FT. STORIES TYPE CONSTRUCTION
will du the work,and the structure is not intendedor offcrcd for sale(Sec.?044,Business
and Professions Coale:The Contractors License Law does not apply on an owner of
pmpeny who builds or improves themor,and who does such work himselfor through his OCC.GROUP RIS.UNITS
wn employees,provided that such improvements are not imended or offered fur sale.If,
however,the building orimprovem nd is sold withinone yeuofeampletion,theowner- TOTAL:
builder will have the burden of proving that he did not build of improve fm purpose of
sale.).
❑ I,asownerofthepropeny,amexclusivelyconwctingwhhlicens con.acomto QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
mn tract the Project(Sec.0044,Business and Profeasimts CNet)The Contractors PERMIT ISSUANCE
License Luwdoes not apply to an ownerafpmpenywho builds or improves thereon,end
who contracts for such projects with a contortions)licensed pumort to the Connreors
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 rat exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE IDE .-9
SANITARY Y_N
Owns Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ I hereby affrm that l have a cenlfcate nfconsem to self-insure,or a certificate of RECEIPT#
Worken'Cmnpensetion Insurance oraanified copy therwf(Sec.Jg00,lsb CJ which FIXTURES-PP.R TRAP PARK FEE Y N
Povers all emgloyejTsWtt#hisme�it. �^ BUILDING DIVISION FEES
olicy# ([[JJ dd !! OO 66 I- GAS-EA.SYSTEM-I INC.4 OUTLETS
Compact $rA t' ate GAS-EA.SYSTEM-OVER 4(FA) PLANCHECK FEE
❑ CatifiNcopyisherebyfumished.
❑ Cenified copy is filth with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP SOILS FEE
COMPENSATION INSURANCE
(This action need not he completed iRhe permit is for one hundred dollars(5100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
T comfy that in the performance of Ne work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
at employ my person in any manner an as o become subject to the WorkersPAID
z Compensation Laws of C.lifomia. Dam /I
WATER SYSTEMREATING Data Receipt#
O O Applicant
NOTICE TO APPLICANT:If,after making this Cenificare of Hxempti......should NEW RESIDENTIAL PCMB. SQ.FT. TOTAL:
F' VJ become subject o the Workers Compensation provisions oftbe Labor Code.you must
4>C 7 forthwith comply with such provisions or this permit"I be domed revoked. BUILDING FEE
SII Z CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that there is a construction lending agency for the pmonar race of
V O the work for which this pemdt is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
LI. Lender's Name PLUMBING FEC
Lender'a Address QTY. MECHANICAL PERMIT PER.
LU1 certify that I have read this.#plication and sate that the abve oinn
foamon is
correct.Iagrte mcomply with all city and county mdinancn and state laws reducing to PERMIT ISSUANCE MECHANICAL FEE
Lo) building construction,and hereby authorize representatives ofthis city to enter upon the CONSTRUCTION TAX
U Z aboventemioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep humless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER IQ000 CFM)
Signuure of ApplicanUCoatractor Dam EXHAUST HOOD(WIDUC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Data Receipt#
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER I00,00011M) O
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
CNe.Section 25532(a)?
11 Yea 11 Na VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
Willtheepplicantarfuwrebuildingoecupanmuequipmcntardevittswhichernit B0ILF?R-COMP(3NPOR 100,010 BTU) p
Instruments air contaminants as refusal by the Bay Area Air Quality Management BOILER-COMP(OVF.R IW,tYI)BTU) IP
DDistrict? e
❑Yes ❑No NEW RESIDENTIALMECIL SQ.FT.
I have rc.J the haznrdova materiels requirements under Chapter
6.95 of the �ss as JJJa'S
Califomia calth&Safety Code.Sections 25505,25533 and 29534. 1understandthat MIN
if rhe hung does not c gently have a tenant.Nm it B my responsibility to newly the
cup I f the requir tfnu which r to issuance of.Cenific _ U VUr�
a
erman oredagent Dam - L: ISSUED BY:
OFFIC