26126 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING.hUKUTRICAL PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL /� Q
BUILDING DIVISION - - ItUILDING PROJECI'IDENT'IFICA'TION G V
BUILDING ADDRESS: ha SANITARY NO. APPLICATIONSSUU.BMI TTTYALDATE
Ns/{ UNITp LOTH , `.g►--g
&WNS.N.A.MB: PHONE,: CONTRACTOR'S NAME: LIC N/CNGINF.ER: I LIC NO: ADDRESS: ❑ L
4� O a
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. -ELECTRIC PLRMIT FEE
ELC PLU I
(p PERMIT ISSUANCE JLDP
LICENSED CONTRACfOR'S DECLARATION AppLIANCES-RESIDENTIAL JOB DESCRIPTION
0CZ Ihereby affirm that Lou licenved underprovisionsofatiner9(commencing with
[sJ O W Nation 1000)of Division 3 of the Business and Professions Code,and my[icon.is in PANELS
Fe full force and effect. UP T0200AMP5
<< Liccnu Class Lic.g
y60. Date Conwctm 201-Iqp AMPS
DW
Oh SQ.ff. pppOOO��pt kkkRRR -
F t%p ARCHITHLTS DECLARATION OVER IAMPS
ZLEV
OZ G'O I understand my plans shall be used u public records.
r ti SIGNS ELECTRICAL
�a�dd LicensedProfessional
pdW6 OWNER-BUILDER DECLARATION SPECIAL CIRCIBT/MISC, %,to
Cw
pyx4,OdU I hereby umrm that Pam exempt from the Contractor.License Law for the 5+ <�
G>✓a0. following mown,(Section]031.5,Business and Professions Code:My city ar county TEMP.MID ER OR POLE INST.
Oy which requires a permit to construct.alta,improve,demolish,or repair any smsemre
INl oor to its issuance,also res the lievnt for such POWER DEVICES
Q� p regm pp permiuo file statement
p that he is licensed pursuant in the provisions of the Contractors License Law(Chapter ,!
d0.o� 9(commencing with Senion1000)of DiviaionJo(the Business and Professions Cale) SWIMMING POOL ELECTRIC VALUATION
Iy aor Sethat oheis exempnyapplimand she for u permit sujeasegedexemptt to Civiny lo[ation of OUTLETS.SWITCHES-FIXTURES
Y Sat...than byes andledicamm($permit subjects the nDDlicenuoacivil penahyo L
0 not more then five handled dollars(ES)YJ). NEWRESIDENTIALELECTR _SQ.FT. \�%
❑ othewrk.Didcesomeo,rnmyemtended eeswithwedaavthei(m. 0LU,Business
.don. STORIES/ 'TYPE CONSTRUCTION
will dothewons C d the he Contra Corm kende Law does not apply to s�n owner
of
and Professions Cade:The Contncmis License Low does not apply m an owner of
property,whobui[dsorimpmves Hereon,and whodoes such work Nmeaforrhmughhis OCC.GROUP RES.UNITS
wnemployees,providrimpr ve=ntiswld itWn neyeuofedmo)feted Tortola.If,
milder will building carimprovementishathe did noneyem of completion,theowner- ]
builder will have @c burden of proving that he did not buil)or improve for purpose of '
sale.).
❑ I,mownerofrhepmpeny.amexelmivelyconnactingwithlicens onuanomo QTY. PLUMBING PERMIT FEE FLOOD O C APN
construct she project(Sec.1044,Business and Prafexiom," e1)The Comrusors PERMIT ISSUANCE
License LawdoesnotapplymasownsofIm MwhobuiIdsmintprovesthereon,and
who contracts forsuch projects with awntramor(s)ficenud punuannodm Conaector'v
Licnu law. pLTIeR-DRAINffi VENT-WATER(EA) FEE SUMMARY
❑e 1 am exempt under SeC. ,B as P C--has reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Dem RECEIPTN
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF. COND. SCHOOL TAX YN
❑ Thereby affirm that haveacmificam ofconunuo ulf-insure.ora cenificam of �� ECEIPPN
Workers Compensation insurance Cr a certified copy thercof(Sm.3800,lab C.)which MIXTURES PER TRAP PARK FEE Y N
covers all employee's under this permit GAS-EA.SYSTEM- INC.4 OUTLETS 1PT M
Policy It BLJ&C1tADPHS FEES
Company GAS-EA.SYSTEM-OVP.R 4IFA) PLANC14EC
❑ Certified copy is hereby famished.
❑ Cenified copy is filed wih,h,city inspection division. GRE.ASEIINDUSTRL WASTE INTERCEPTOR GRAD III
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP 5011 r�
COMPENSATION INSURANCE
(This section need Out he completed if the permit is for one hundred dollars(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
carless.)
I certify that nine perfxonanccofihe work for which this permit is issued,]shall WATER HEATER W/VENT/ELECTR
not employ say person in any m e
s o as m becomsubject to the Workers PAID
Z Compenxtion Lawsof Califomia. Data WATER SYSTEMnREATING Date
Applicant
Z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,PT. TOTAL:
become subject to the Warmers Compevram provision of the Lebor Cade,you must
nhw
foithcompiy with such provisionam this permit shall bedeemed revoked. BUILDING FEE �R
z CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the performance of ELECTRIC FEE
L) O the work for which this permit is issued(Sec.3091,civ.C.)
L3. ELenders Name PLUMBING FEE
O Lenders Address QTY. MECHANICAL PERMIT FEE
I certify that 1 have read th a application end state that the above information is
aour cel.I agree to comply with a city and county ordinances and state laws reining to PERM IT ISSUANCE MECHANICAL FF
buildings . .H
andhC.b amhorim rcprcsenmtivea o0his city so enteruprmhe CONSTRUCTIONTAX
V y above- a inionW pr y for spection pu s. ALTER OR ADD TO MECIL
C7 (We)agree m s v,led mify and less the City of Cupertino agvmt
IiAilifiespilgmenB, ants expeme i idn"tuiciCity AIR HANDLING UNIT(TO 10.000 CFM)
in xque of th rJr of,
I AIR HANDLING UN (OVER IgCFM)
aturc of ant/Co mmo Date EXHAUST HOOD(WIT 000/DUC) PAID
ILAZARDOU MAT SCLOSURB HEATING UNIT(TO 100,000 BTU) ./ Date Receipt
Will the applicant Or future b occupant store or handle hawdous material
Is defined by the Cupertino Municipal Cede,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 1W."BTU) �• TOTAL
Coda Section 25532(e)P
E)Y. 11 No VENTILATION PAN(SINGLE RESID)
BOILER-COMP(314P OR 1(10,009 BTU) A ISSUANCE DATE
Will the upplicnnmr)umrebuildingnccupant useequipmnnordeviceswhichemit Pe
hurardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 10I BTU) A 1,D
District? ����
13 Yet ❑Na NEW RESIDENTIAL MECH. SQ.Fq'.
I have mad the hermdous materials requirements under Chapter 6.95 of the '
California Health ffi Safety Code,Sections 25505,25533 and 25534. I understand that
if the building does not currently have a nonan,that it is my responsibility to notifythe �h LU ��
occupant of the requirements which must to met prior to issuance of a Cenificme of ~C�yQ
Occupancy. V
Owner or aothoriud agent Date ISSUED
OFFICE _ -