26404APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERT[NO - B IL 1 . - F.LEUTRI AL
BUILDING DIVISION APPLICATIONMERMIT PLUMBING -MECHANICAL
PROJECTIDENTIFICA'1'[ON
PERMIT NO.
26404_BUILDING
BUILDING ADDRESS
�:
LOT III
SANITARY NO.
AOP`PLLIICATIONNSSUUBINWITALDATP:
J� Ing
,
OWN SN.... : PHONE:
�� YO.
CO CfOR'$ M
LIC NO:
N/C
❑
CONTROL#
RC CT/ENGINEER: LIC NO:
ADDRESS:
CONTACT: PHONE:
QTY. ELECTRIC PERMIT PEE.
BUILDING PERMIT INFO
BLDG ELECTPLUMB MECI
PERMIT ISSUANCE
j E
LICENSED CONTRACTOR'S DECLARATION
I herehy affi mm Nat I am I icensN under provisions of Chapter 9 (commenci ng wi N
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
PANELS
full Pone andefDivision 3 of the Business and Rvfeesions Code, and my license is in
full effect.
w
LicenseClad
License Class Lic.N
UP TO 200 AMPS
I(,r—.�
��
Dam Contractor
201 - 1030 AMPS
ARCHITECTS DECLARATION
1 understand my plans shall be mud as public rtcards.
OVER 1000 AMPS
SQ. FT. FLOOR AREA 1/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC. Al
In I N
that I am exempt from Ne Casson, o License Law for the
I hereby n,
m Imo'/ �1
TEMP. METER OR POLE INST. '
following reason. (Section 7031.5. Business and Profmsime Cade: Any city or county
Se
which requires a Permit to construct, ultra, improve, demolish, m repair any structurt-
primtoirsissuance, sham requires NeapPlicant fmsuch permit to filen sigrlWsmumsm
POWER DEVICES �5
that he is licensed pursuant .,he provisions of Ne Contractors License Law (Chapter
9(commencing with Section 7")of Division 3 of the Business and Professions Code)
VALUATIpN '
SWIMMING POOL ELECTRIC
.,,he, he is exempt herefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a Permit subjects the afflicted to a civil penalty of
fY
OUTLETS - SWITCHES - FIXTURES s----
re than five hundred dollars (S50%
I, usowneroftheproperty,ormyemploymxwiN wegesuNeiralecompensation,
NEWRESIDENTIALELECTR _SQ.FT.
STORIES
TYPE CONSTRUCTION
well he work,undtheslmcture isnml inundedmmffere4 forsale($m. ]tN4,Busineas
and Pro awns Cade: The Contractors License Law does not appy to an owner of
property, whnbuilds orimproves domer ,nndwhoduessuchwark himaelfurthrough his
ownemployces,pmvidedtatsuchimpmvementsmmtintendedOrOffCTedforsate. If,
OCCGROUP
RES.UNIN
TOTAL:
however, the building or improvement is sold wid inane year of completion, the owner-
budder will have the burden of pmving that he did not build or improve for purpose of
'
QTY. PLUMBING PERMIT FEE
sale.).
❑ I.mownermflhepmpeny,amexclusivelyronvactingwiNlicasM..Ctorsto
FLOOD ZONE
APN
construct the pmjecl (Sm. 704q Business and Professions Code:) The Convector's
License Law does not apply to an owner ofpmpeny who builds or improves themon, and
PERMIT ISSUANCE /
whocmmmcts for such projects with acontractons) licensed n omentm the Contractor's
License Law.
AL1 E0.- GRAIN &VENT (E
WATER A)
FEE SUMMARY
❑ I am exempt under Sec. , B & P C for this resson
BACK FLOW PROTECT. DEVICEOUTSI
SANITARY Y N
RECHIPTIs
Owner Date
DRAINS - FLOORROOFAREA.COND.
. .
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX Y N
❑ ihercby affirm thmlhave¢certificate of wnxnt to self -insure. ore eertificnte ofLo
Workers Compensation lnaurace in a cenificd copy thereof (Sm. 3800, Lab C.) which
,,.vers all employee's underthie permit
Polcy M
RECEIPT
FIXTURES . PER TRAP
77
PARK FEE Y N
p
GAS - EA. SYSTEM-] INCA OUTLETS
BUILDING DIVISION FEES
BUILDING
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PI A ICHECK FEE
❑ Certified copy is hereby famished.
GREASPANDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Crnlfied copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS TLE
COMPENSATION INSURANCE
SEWER- SANITARY- ST ORM EA. 200FT.
ENERGY FEB
(This section need notbe completed ifahe permit is foronshundred dollars ($100)
or less.)
WATER HEATER W/VEJT/ELECRt
I certify that in the performance of the work for which Nis permit is issued, I&hilll
not employ any person in my manner m as to become subject to the Workers
PAID
Compensation Lawaof Califomia. Data
WATER SYSTEM/IREATING
Date Rmeipo#
Applicant
NEW RESIDENTIAL PI.MB. SQ. FT.
TOTAL:
NOTICE TO APPLICANT: If, after making this California of Exemption, you should
Mcmme subject m the Workers Compensation provisions of the Lahor Cade, you must
forthwith comply with such provisions or this permit shall be deemed revoked,
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm Thar Nem is a communion lending agency for the performmce of
the work Permit for which this peit is issued (Sec. 309], Civ. C.)
O A
ELECTRIC FEE
Lenders Name
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
Lender's Address
I certify that l have read this application and state that the above information is
correct. l agrm to comply with all city and county ordinances and &tam laws relining to
PERMIT ISSUANCE
MECHANICAL FEE
building convection, and hereby and mrixreprexnmtives o(the city toemmr upon the
above-mentioned property fm inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) ague to save,' mrify and keep harm) City of Cupertino opens,liubiIies.jud
coca, dexpnexaswhic way xcrueagaintxid City
AIR HANDLING UNIT GO 10,000 CFM)
c ce of ting of Nis peri
✓
AIR HANDLING UNIT (OVER IO,000 CFM)
EXHAUST HOOD (W/DUC )
PAID
'SignatImo ApplicanUContractor Dau
HEATING UNIT GPO 130,0D0 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dam Receipt#
HEATING UNIT (OVER 100,000 BTL)
TOTAL:
Will the applicant or future building occupant store or handle harardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, utd the Health and Safety
VENTILATION FAN (SINGLE RESID)
��
Code, Section 25532(n)1
11 Yes ❑ No
ISSUANCE DATE
Will theapplicantorfulurebuildin,occupant use equipmentmdsviesswhich alis
BOILER- COMPQHPOR 130000 BTU)
BOILER - COMP(OVER 100,030 BTU)
anomalous air commormmu ss defined by she Bay Area Air Quality Management
District?
P
NL•W RESIDENTIAL MECH. SQ. FT.
❑ Yes ❑ No
A 9
1 have read the hazardous actions acquirements under Chapter of the
gy
CaliforniahbuilHealth & Safety Code, understand
Sections 25505, 25533 and 1 understand Net
((�V��a t7 1A(�A
WAY 1
have a tenant. notify the
if the building ams ml have responsibility
o is my reuance
aia7`f
mentacurrently
of a e
upmt of the requirtmems which must be mel prim to issuance of a Certificate of
et f
Occupancy.
(xIh'
CRY ! �II
ISSUED BY:
Owner ar mammal agent Data
TOTAL:
OFFICE