26554 APPLICANT TO FILL IN INFORMATION WFSHIN RED LINES-USE BALL POINT PEN ONLY
BUH:UIEI., R AI. PGRMI'I'NO.
CITY OFCUPERTINO APPLICATION/PERMIT PLUMBING-MECHANICAL26554
BUILDING DIVISION BUILDING PROJECT IURN'19FICATION
BUILDING DRESS: // pp SANITARY NO. APPLICATION SUBMITTAL DA'IE
Tft LOTH
OWNERS NAME: PHONE: �[� �1 CI'OR'SNAME: LIC NO'.
NIC COM'ROLX
/rNGINEER: LIC NO� ADDRESS: ❑
CONTACT: PHONE: QTY, LLECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECTPI MB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DE$CRIPTI
K
1 hereby affirm that 1 am licensed under provisions ofChapter9(commencing with
+400 Section 90W)of Division of the Business and Pro[cssions Coal and my license is in PANELS
ymQF Q y fulland dfcl. UP T02MAMPSUa License Lic.# ��n1"
Data
ConTS D OVER
-KILO AMPS SQ.FT.FLOOR AREA $/SQ.FI'.
ZC,o— ARCHITECTS DECLARAItON OVER 1000 AMPS
O Z f-� I understand my plans shall be used as public records. _
SIGNS ELECTRICAL
24Ej Licensed Professiowl I'I (III �k
aCQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT'/MISC. L F D II N
X 0 c.
W1 hereby spoon that I am exempt from the Comuncmrs License Law for the
m•3 ay following reason.(Section 9031.5,Business and Professions Code:Any city or county t'EMP.METER OR POLE(NST.
t a00< which requires a permit to curstruct,alter,improve,demolish,or repair any structure POWER DEVICES
cait� � prior(oils issuance.aktioduiresthe nPPliesm for such permit to file a important signed iortant
C that heli lloemsedfamusnno the powisionsofthe Commdaw,License Law(Chewer 1
SWIMMING POOL ELECTRIC 10
sync 9(comormlargwith Section 400()of Division 3 of the Business and Professions Code) LUAT
W-m or list he is excempuherefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-Fl%TURES
F Z Q Section 7031.5 by any upplican(for a permit subjems the applicant to a civil penally of
5Eq wa wine than five hundred dollars H500). NEW RESIDENTIALELECTR _SQ.FT. STORIES '1'Y'ECONSMUCTION
acq ❑ I,asownero[thcpmpeny,ormyemployees whh wagesus Ncirsoleeompensntinn
arm wilimfluawork,and the slmctua isnot lntendedoroR red[m sale(Sec.9044.Busives+
and placation,CWC:The Compactor,License Law docs nal apply to an owner of
property who buildsor improves thcrismand whodree such work himselfor lhroughhis OC GGROUP RES.UNITS
con employees,providedthat sucM1 impmvemcrosnre nolimendedorofferedform sale.If,
however,the buildingor improvement Is sold within one year of completion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sole.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ I,as owner oflhe property,am exclusively contracting with licensed exammemrs to
onatmm the project(Sce,9044,Business and Professions COde:)The Contractors PERMIT ISSUANCE
License Lawdoc.s not apply to an owncrofpropeny,whobuildsorlmproves thereon,laid
who contracts for such prmccm with aeonpamm N
ar(s)licensed pursuant e Cranstor's ALTER-GRAIN&VENT-WATER(EA) FEE SUMMARY
License Law.
❑
Tam exempt under Sea. ,B&PC for this reason OUTSIDE.FEES
BACK FLOW PROTECT.DEVICE. SANITARY YN
RECEIPT p
Owner Dale
DRAINS-FLOOR,ROOT:,AREA,COND. SCHOOL TAX YN
WORKMAN COMPENSATION DECLARATION RECGIPI'#
'❑ •I hereby affirm Nap l have a certificate ofeomsenun self-insrs,or a cenifeatc of FIXTURES-PER TRAP PARK FEE Y N
,,'Compensation humour«or a cenifiedcopy themof(Sce 3800,Lab C.)which RECEIPT#
covers all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLE'T'S BUILDING DIVISION FEES
Policy#
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cenifedcopy kInwabyfumished.
❑ Cfnfled copy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one hundred dollen 0100) SEWER-SANITARY-STORM EA.200FT. PE=RICHE
orle".)
Icenilythal in Nc performance of Nc work fnrwM1ichthis permit is issued, WATER HEATER W/VENt'/F.LECTR
not employ any Iverson in any manner. as to become subject to the Workers
Compensation Lawsof Califomia. Date so WATER SYSTEM/rRGTING Receipt#
o Z Apphcsm NEW""IDENTIAL'LMB SQ.F . OTAL
Z 0 NOT ICE TO APPLICANT:ILafe,making this Cenificate of Exemption.you should
Cn become subject to the Worker's Compensation provisions of Ne Labor Code,you must
7 forthwith comply will,such provisions or permit shall be deemed revoked
p,, Q CONSTRUCTION LENDING AGENCY
�s Z I hereby affirm that there is stultification lending agency for The pefformance of TOTAL:
lCJ the work for which his peonh is issued(Sou 3097,Civ,C.)
Lenders Name PLUMBING FEE
u" F Lender's Address QTY. MECHANICAL PERMIT FEE
0 U c I certify that I have read this application laid stem the(the above information is MECHANICAL FEE
�'+ W rem.Iagree m comply with all city and county ordinances and smte laws relating to PERMIT ISSUANCE
F building construction,and hereby salumile representatives'fill"city to enter upon the CONSTRUCTION TAX
z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
U
(We)egret to save,indemnify and keep hno^less the City of Cupertino against AIR HANDLING UNIT(TO 10,00)CFM)
Ilubilities,judgmems.cwt;and expenses which may in any waynecmritipu stsaid City
in cpm sequence of the granting of this peril AIR HANDLING UNIT(OVER IO,WO CPM)
Signature of Appll9r Date EXHAUST HOOD(W/DUCT) PAID
IIAZARDOUS MAl'ERIALS DISCLOSURE
HEATING UNIT(TO 100,0 BTU) Date Reccipt#
Will the shpt icnpnfertile firs,Mnbuilal Code,Chapter 9.12,
and
Health and Safety
HEATING UNIT(OVER IW.000 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Core,Section 25532(#)'1 VENTILATION FAN(SINGLE RESID)
❑Yes ❑No ISSUANCE DATE
BOILER-COMP CTHP OR 100,000 BTU)
,
Will the applicant or f umre building«cupanmse equipment m devices whicM1 emit
bourdom air cmvminams as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100.000 B'I'U)
Distort?
❑Yns ❑No NEW RESIDENTIAL MECH. SQ.FT. pp
I have read the hazardous materials requirements under Chapter 6.95 of the P H 1'n 0
California l leallh&Safety Code,Sections 25505.25533 and 25534. 1 undeamndthat w
if the building does no(currently have a temml that it is my responsibility to notify the
occupant of the requirements which mus(IN,mel prior to issuance of a Certificate of {S
Occupancy. //���
Y'1.1.
Owner or aulM1orired#gem Date TOTAL: ISSUED RYr
OFFICE rtH/rryU