26440 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO26440
B I. 1. i-LLL 'IRI AI. PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECTIDEENN''1'IFICA'1'10
BUILDING ADDRESS: Wn.L �r\x �I SANITARY NO. APPLICKHONSUBMfITALDATE
.=f UNITJ#lr LOT
OWNERS NAME: PHONE: CONTRACTOR'S NAME: } LIC NO: N/C COMROLp
JZJ
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ARC]111 LC'DENGINF, : IC NO: ADDRESS:
I
CONTACT: JIt. Nl.GBry s (sPHOWi: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
PERMIT ISSUANCE fsa El El El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL P� JOB DESCRIPTION
cwz Ihercbynffirtn NaU am licenxJ under provisions ofCTapmr9(commencingwith J f l
00 Said..]0007 of Division 3 of the Business and Professions Cale,and my license is in PANELS / ` I•ak•W
fol I force vnd if t. p
FZtaI Liccmc Lic.p 1p� UPTO 200 AMPS Kir - -
y?y Dam Contrxnor I.JII 201-1001 AMP. SQ.PI'.II,GGR AREA $/SQ.IT.
�mZ ` ARCHI'TECT'S DECLARATION OVER IMNI SIGNS ELECfR 'A
AMI v
I zoo,— I undecatvnd my plans shall be used as public records.
rhl uw _
<y�, Licensed Prafcasional
KC WQ OWNER BUILDER DECLARATION SPECIAL CIRC /M
KO a V I hereby off that I am exempt from the Contractors License law for the
m 3 a y following reason.(Section 7031.5.Business end Professions Code:Any city m county TEMP.METER OV POLE INST.
F-a o Q which requires a permit to construct.alter,improve.demolish,or repair any structure
>� to its issuance,also the applicant for such permit file asi nedstemmem POWER EVICES
prior rcgwrcs pp pcmm g
cA a0 p that he is licensed pursuant to the Provisions of the Contractors License Low(Chapter SWIM TNG POOL ELECIftIC
6i°�o 9(commencing with Section]000)of Division 3 ofthe Business and Professions Cede) VALUATION
kv..m mrmm M1e lsexempnhererrnm and me naaix Tar the aueged«empdon.AnYviolmioaof 535, 00 KD9
Y Section 90311b OUTLETS-SWITCHES-FIXTURES
B.Z yv hundred dollars
subjects the applicant toacivll penally o[
� C n tml,asown rofbedred Jallarmyemp. NEW RF.SIDIihIT1AL ELECIR SQ,FT. STORIES TYPE CONSTRUCTION
C o ❑ othe wrk.andepmpeny,e is not
forside sthei(See7m.Brauoo,
a3°= willdothesions and the heCcoractorelsnut intenense Law does not
in an owner
and Professions Cade:The Contrecmrx License Law dues not hilly to an owner of
property who builds or impmvax theme.vnd whence,such work himulf edthrough his
ownOCC.GROUP NIS.UNITS
employees.prov.,ithat suchimpmvdd wit arranot earwiMoroffemd farwwa IL
however.Neavet the
improvementissoldwithinoraeyear ofc prove for thrower- TOTAL: C
builder will have the burden of proving that he did not build or improve for purpose of d
5°1c')' QTY. PLUMBING PERMIT FEE
❑ Lmownerofthepropeny.rim exduxivdy ronvacting with limnxd cumrunun to FLOOD LONE, VdPN
instruct the project(Sec.70W,Business and Professions Code:)The Contractor's
License Low doesnotvpply to an ownerofpropeny,whomildsor improves thereon,and PERMITISSUANCE
who contracts forsuch projects with a aamrumor(s)licensed pursuant o the Contractor's
Liccnu Law. ACfER-DRAIN&VENT-WATER(EA) FEE$UM
❑ I am exempt under Sec .B&P C fur thin reason BACK FLOW PROTECT.DEVICE OUTSIDE
SANITARY
Owner Dare DRAINS-FLOOR,ROOF.AREA,CONE. : To
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y
Ihemby affirmNm thoraco cenificme of conumto self-insurt,mattnificam of FIXTURES-PERT R .PTn
Workers Compensation Insurance ora certified copy thereof(Sec.3800.Lab C.)which PARK FEE
crsall emLtoycq's under this drat EC PT g
Policya 1ECgl1-13 �9G GAS 11 C. OUT. ILD TVI
Can Cert Tag,
isez1-.g—Jd. GAS- A.SYSTE OV (EA) PLANCIIECK FEE
Certified copy is hereby famished.
Cmilied copy is filed wish the city inspection division. GREASE./INDUSTR WAS INTERCGVTORGRADING 19EIi
CERTIFICATE OFEXEMPTION FROM WORKERS' GRIEASETNAP SOILS FIFE
COMPENSATION INSURANCE
(This section nerd not he completed lfthe permit is for one hundred dollars(SIM) SEWER-SANITARY-STORM EA.2MFT. .Y FT;E
or leas.)
I canny Net in the perfomamce wDhe work for which this Permit is issucd.I shall -WATER HEATIER W/VENT/ELECIR
not employ any person in any manner so as to became subject to the Workers' PAID
Compensationlawsof Cahmania. Date WATER SYSTEM/TREATING Date Receipt
Applicant
zQ NOTICE TO APPLICAM':1 L after making this Certificate of Exemption,you should NEWRESIDENTALPLMB. SQ.FT. TOTAL:
(q become.mbject to the Worker's Compensation provisionsofthe Lan Cale,you must BUILDINGTEG
CONS'IRl1Cl'ION LENDING AGENCY
a ; forthwith comply with such provisions a this permit shall be Jecmed revoked.
W0. Q SEI SM IC IT 17.
1 thereby affirm In.there is o a..mclim lending agency for the performance of
V OZ) z 'TOTAL: ELECTRIC THE
work far which this permit is issue)TSec.3(19],Civ.CJ
Lender's Nome PLUMBING FEE
C F Lcnde,Address QTY. MECHANICAL PERMIT FEE
V I certify that I have mad this applieaion and saw for he above information is MECHANICAL FEE�•' anted. I agree to comply with all city and county ordinances and state laws relining m PERMIT ISSUANCE
building construction.and hereby amhente mpresentativesofthiscity to enter upon the
alive-mentioned n for inspection ALTER OR ADD TO MECH. CONSTRUCTION TAX
V Z 1.sue Y Pec' Purposes.
(Wc)agree nt cave,indemnify and keep harmless the City of Cupensts against
liuhiliiics,judgments,costs and expenses which may in any way some against said Ciry AIR HANDLING UNIT(TO 10.000 CPM)
in cnn equenee of the granting of lois pomrit.
AIR HANDLING I IT(OVT 10.000 CPM)
11,coun,of Applicaro Cuntmctor Dom EXHAUSTHOOU /DU PAID
HAZARDOUS MATERIALS DISCLOSURE HEAPING UNIT B ) Dole Rimini It
Will Lie applicant or future building occupant stem or handle hmardous minimal I{EATING E BT1B T
as defined by the Cupertino Municipal Cah,Chapter 9.12,and the Health rand Safety ,Q
Code,Section 25532(0? VENTILATION F N(SINGLE RESID) Y -d
t 11 t-
11 Yes C�rNo
BOILER-COMP(3HPOR INJOW BTU) � 4 ISS NCE DATE
Will the aMlicam or future buildiagaccupant useequipmenmrdevices whichemit '/, Y eg
o'aeurdam am
air contaminants as refined by the Bay Area Air Quality Management BOILER-COME(OVER 100,000 BTU) J 1LI(�
SDisvin'! k
❑Yee �No NEW RESNIENI'IAI.MECII,—SQ.FL.
I have read the hazardous materials requirements under Chapter 6.95 of the Y crt�//��
Califmnis Health&Safety Code,Sections 25505,25533 and 2553,1. I understand that v
if the building does not currently have a mnmfast at it is my responsibility to notify the
occupant of the requirements which must be met prior m issuance of a Certificate of
Occupancy.
Ownoramhodae age Dale TOTAL: ISSUED BY:
OFFICE