26292 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
'CITY OFCUPESIONO APPLICATION/PERMIT PLUMBING-MECHANICAL PERMIT NO.
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 26292
BUILDING ADDR S: ♦ SANITARY NO. APPLICATIONSUBMITTALDATE
^"' LOT#
"E:255-7G3 ONT C RSS NA E: LIC NO:
(J`� N/C CONTROLp
'ARCHITIPT/ENGINEER: LIC NO: ADDRESS: ❑
ONE
CONTACT: PH : BUILDING PERMIT INFO /
G-arj M 761
--7y'-/7 QTY. ELECTRIC PERMIT FEB
BLDG ELECT PLUMB
PERMIT ISSUANCE safs-
LICP.Ng CONTRACfOR'SDECLARATION APPLIANCES-RESIDENTIAL
WmwzOO Iheroby affirm thaU am licensedBustrader and
provisions ofChaprer9 and
(commencing with LOB DESCRIPTION
�t0 full force and of Divie on 3 of The Business end Professions Code,and my license is in pgNPLg -
I
CV License
Class efface - UPT0200AMPS
4 z License Class Lic.#
y<y Data Contractor - 20I-1000 AMPS
zc)-i'� ARCh1ITECT'SDECLARATION OVER EXT)AMPS SQ.FT.FLOOR AREA $/SQ.FT.
OZ—MOZ-M I understand my plans shall be used as public recortls. �
SIGNS ELECTRICAL
y , W
q'^ �
Licensed Profess�onul
Ly OWNER-BUILDER the Con TION SPECIAL CIRCUIT/MISC.
OLF 1 hereby affirm that 1 am exempt from @c Convnetore License Law for the
3 m following reason.(Section]OJLS.Business and Professions Code:Any city or county TEMP.METER OR POLE INST,
IJ to which requires a permit to comfort,alter,improve,demolish,or repair any structure
}
prior but its issuance,also requires the applieam forsuch permit to file a signed statement POWER DEVICES
sDW Q p that he is licensed Financial to the provisions of The Contmnors License Law(Chapter
ace 9(commencing with Section 7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION �a_
Wmi, or that he is exempt and the basis for the alleged exemption.Any violation of !'� ^ IVT�R
7�< Section]0315 by any applicam far a Permit subjects Ne applicant m u civil penalty of OUTLETS-SWITCHES-FIXTURES �^ /J�S
���7�17�17�1�1''''G not mora uhun five hundred dollars(5500).
C� [ILasownerefthe property,ormy employees with wagesastheirsolecompansman, NEWRESIDENTIALELECTR _SQ.FT. STORI TYPE CONSTRUCTION
y willdo the work,andthe structure limit intended.roffered forsele(Sec.]014,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
property who bui Ids or improves thereon,and who does such work himseBar=
f ar uhmogh his
wnemployees,pmvidMthatsuchimpmvemems arenotintent or offered Tarsale.If, OCO GROUP EA
however,the building orlmproo mens is sold withinone yearofcompletion,meowner-
builder will have the burden ofpmving that he did not build or improve for purinse of
sale.).
❑ I,asownerofthepmply,emexclusivelyconvactingwiN]icensedcomrecto to QT' PLUMBING PERMIT FEE FLOODZONE
consumer the project(Sec.]014,Business and Professions Code:)The Contractor's
License Law does notapply to shownrofpropetty,who builds orimprovesthereoq and PERMITISSUANCE
who contracts for such projects with acontractors)licensed pursuanttu the Commeaov's
Licee Law. ALTER-DRAIN&VENT-WATER EA) FE
nsE SUMMARY
❑ I em exempt under gee. ,B&P C for this mason BACK FLOW PROTECT.DEVICE OUT IDE FEES
SANITARY Y—N
—
Date Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL.TAX Y N
❑ Iheroby affirm that lhave ecenifice¢of consem mselGiasure,or a cer[ifcete of FIXTURES-PER TRAP RECEIPT#
Workers'Compensation Insurance or acetified copy thereof(Sec.3800,Lab C.j which PARK FEE Y N
covers all enpleyee's under This permit. GAS-FA.SYSTEM i INC. 0UTLF.Tg E IFI'#
Policy N VISION FEES
Company GAS-E;CSYSTEM-OVER4(EA) PLANC O
El Certified copy is hereby famished.
❑ Certified copy is fled with the city inspection division. GREASE/IN E
_ GRADING
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETR - SOILS FEE /
COMPENSATION INSURANCE It `n
(This section need not be completed if the permit is for one hundred dollars BU 0d) SEWER-SANT ARY-STORM EA. E
mleas.) T. ENERGY FEE
..II��ee''
Icertifythentinrusisaformance.fihe work forwhich this permit is issued,l shall WATE HEATEy#ryTa/ELECTR
not employ any person in any manner so as to become subject to the Workers' p D
Z Compensation Laws of Califemia. Date WATER SYSTEM(HEATING Dem ReceiptN
Applicant .
Z
C. be-com TO AP.the W T.If,after Compassed.
this of the
[.be,Exemption,de,youshould
most NEW RESIDENTIAL PCMB. SQ.FT. TOTAL:
> becomesuomply the Workers Compensationprovisions., hall b,he laborwided.umust
forthwith comply with such provisions or permit shall be demand revoked. BUILDING EEE rr#
LTa Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
7-r I hereby affirm that there is a meed(Sec.
3 lending agency for the performance of
U O the work for which this permit is issued(Sec.309],Civ.CJ ELECTRIC PEE �.
LL r.r Leader's Name
Lender's Address QTY, MECHANICAL PERMIT FEE PLUMBING FEE
U
U 1 certify that 1 have read this application and stare that the above information is MECHANICAL FEE
carrier.I agree m comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
V) building construction,and hereby authorize namsentativeso(this city to enter upon the CONSTRUCTION TAX
U 7 above-mentioned property for inspection proposes. ALTER OR ADD TO MECII.
^� (We)agree tu save,indemnify and keep harmless the City of Cu vino against
W 11
liabilities,judgments,cos¢and ex nses which may in any way accrue 'no AIR HANDLING UNIT(TO Io,"CFM)
e of the granting. ler r
1G AIR HANDLING UNIT(OVER 10,000 CFM
Z'gareof Applicallogmareactor Data EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,000 BTU) Date Receipt#
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9,12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU)
Code.Section 25532(a)? VENTILATION FAN(SINGLE REgID7 /
❑Yes ❑No
Will the applicamre
orfumbuildiagmns
aacupant maccuipmeordevicwhicbemit BOILER-COMP(3HP OR 100,000 BTU) ISSUANCED
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District? Q
El Yea ❑Nn NEW RESIDENTIAL MECH. SQ.FT.
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health at Safety Code,Sections 25505,25533 and 25534. 1 undemand that r�
if the building does not curtemly have a tenant,that it is my responsibility to notify the
occupant of the requirements which most be me[prior to issuance of a Certificate of C/r
Occupancy. li
Owner or notarized agent Date ISSUED BY, 'rya
OFFICE