26800 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO •) T PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 2 6 8 0 0
°' BUILDINGPROJECT IDEN'1'IFICATIQN'
BUILDING ADDRESS: SANITARY NO. APPLICATIONN�SUBMIMITTAL DATE
O # LOT �y
OWN SN c7eiryIONE: CO CfOR'S AM LIC NO: NIC CO�NTROLM—{s
t 4RCHI DeCTOENGINEER: LIC NO: ADDRESS: ❑
�CONTAC'. PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
DGE PLUMB MECH
PERMIT ISSUANCE 13 El .
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDE AL
0042 I hereby affirm Nat l am licensed underprovisiomofCVter9(commencingwith JOB DESCRIPTION
600 Section 7")of Division J of the Business and Professions Code,and my license is in PANELS
pq Ur full force and effect.
<z License Class Lic.0 UPT 00 S
sn<y Data Contmew 201-
ZC1 so ARCHITECTS DECLARATIONE P5 SQ.FT.FLOOR AREA $/SQ.FT.
O z O 1 understand my plans,huR be used as Public records.
ry�ul E CIRICAL Q
< Licensed Professional
CC ,'V OWNER-BUILDER DECLARATION \ PE AL CIRCUIT/MISC.
OyF An
I hereby affirm that 1 am exempt from the Communities License Law for h
W 3is-rn fallowing reason.(Section 7031.5,Business and Professions Code:Any city or court T MP.METER OR POLE.INST.
fh which mluirc,a permit to construct,alcor,improve,demolish,or repair any&tract e
}� prior to its issuance,also requires the applicant for such permit to file a signed state a POWER DEVICES
<p that he is licctued pursuant o the provisions of the Contractor's License Law(en
9(esmmeneing with Section 700)ofDivision 3 offle Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
-' ❑m or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-,Wn'CHFS-PIXTURE.S �� I�
Section 7031.5 by any applicant for x permit subjects the applicant to a civil penalty of
< not more than fine hundred dollars(8501. NEW RESIDENTIAL ELECIR 5 .PI',
rz�pm ❑ I,nsowneroftheproperry,nrmyempltyeeswith wegesaseheir,olecompensation, Q STORIES TYPECONSTRUCI'ION
L will dothework,and the structure isnot intendedortffered foreele(Sec 709 .Business
and Professions Code:The Contnctoex License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himadfonhrough his OCC,GROUP RHS.UNITS
own employees,provided that such improvements art not intended or offend for sale.If,
however,the building orimprovement is sold within uneyemo(completion,the owner TO
builder will have the burden of proving that he did not build or improve for purpose of
aide)..
❑ 1.as owner ofthe property,amexclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEE FLOODZONE APN
construct the project(Sec.7094,Business and Professions Code:)The Contractor's
Licenu Lawdoesnotapplytoanownewfpmp ywhobuilNmimpnvesther ,wd PERMIT ISSUANCE r/
whocontrecu forsuch patients with acontractor(s)licensed pursuant to the Currencies t
Untrue uw. ALTER-DRAIN&VENT-W TER(EA) - I -. Fl FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEV41i /i 1 r 'A rrAR OUTSI ES N
Owner Data - - RECEIPT#
DRAINS-FLOOR.ROOF.AREA,GOND.
WORKMAN COMPENSATION DECLARATION TAX YN
❑ Ihcmby affirm that)heveacevificote of mnsenno self-inaure,marertifnm of FIXTOgpS-PER TRAP DATE RECEIPT'#
Wmken'Cmvpean6cm insurance ma certified copy thermf(Set.380,UbCJ which -__jl Y N
covestill employee's under this permit GAS-EA.SYSTEM-I INC.4 OUTLETS RF IPf#
Policy# BUILDING IJVISION FEES
Company GAS-EA.SYSTEM-OVER 9(EA) PLANCHECK FEE
C1Cenifted copy is touchy famished, Its, $to
❑ CevifiOd copy i&Bled with the city inspcmiun divi,ion, GREASFgNDUSTRL WASTE INTERCEPTOR GRADING FEE If
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE III
(This section need not he completed ifthe pemtit is forone hundred dollars($IN) SEWER-SANITARY-STORM EA.2011. ENERGY FEE
or less.)
I cavity that in the performance of the work for which this permit is issued,)&hall WATER HEATER W/VF.NT/ELECI'R
not employ any person in any manner so u to become subject to the Worker&' PAID
Cion,ammtant Law&nf Culifurnis Date WATER SYSTEMOREATING to Receiptp
Q z Applicant
z 0 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PI.MB. SQ,Fr. TOTAL:
h V) became subject to the Worker's Compensation provisions of the LaMar Cade,you must
a. forthwith comply with such no,kinix or this permit shall be deemed revoked. BUI Iy
zQ CONSTRUCTION LENDING AGENCY SEI, 1
I hereby affirm that them is u construction lending agency for the performance of
U O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECIRIEME
Lenders Name
QF Lcnderb Address QTY. MF.CHANICALPERMIT FEE PLUMBING
U I certify that 1 have read this application and state that the above information is -
s�' 0. contact, l agree to comply with all city mal county ordinances and state laws relating an PERMIT ISSUANCE MECHANICALEE
F" to building construction.and hereby authorim representatives ofthireity mercer upon the
U z above-mentioned property for inspection purposes. ALTERORADUTOMECH. CONSTRUCfI NTAX
(We .gree to sans,indemnify and kap hamdess the City of Cupertino against
liebiliti ldg On ��ande - hi yw esgi iiousaid Ciry AIRHANDLING UNIT(TO 10,000CFM)
c0 f ting of ermit. AIR HANDLING UNIT(OVER TgUOCFM)
I
Si lumuf APPlicant/Contncm D� EXHAUST HOOD(W/DUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IN,"BTU) Date Receipt#
Will the applicant or future building occupant awe or handle hnsrdous material HEATING UNIT(OVER I0,IKKI BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25512(g?
1:1 Yes 13 No VENTILATION PAN(SINGLE RFSID)
BOILER-COMP DHP OR 10,0 BI U) ISSUANCE DATE
Will theapplicant orfumte buildinguocupent uxamuipmem mdevices which emit
hamedous air contaminmts as defined by the Buy Area Air Quality Management BOILERR'-COMP(OVER 100,BtlB BTU)
Di&tron?
❑Yea ❑No NEW RESIDENTIAL MECH. SQ.FT. P A B
I have read the l acrdnus no enols requir ends code,Chapter 6.95 of the
Citifthe wilding does
&Safety Cady have ons 25505.25533 mtl responsibility
1 tuallustity to nand ohm AUG -1 �gg0
ifthe building Aresnot
ments with utectum,that it I&myresponsibilitytonotify the
Or c upas of the requirements which roust be met prior to issuance of u Cenificam of
ccupuncv. C�i, IJI
Ownersnouthoritedagcat Dote TOTAL: ISSUED BY IIVU
OFF