26115APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO -nz,.1M7CXT
BUILDING DIVISION APPLICATION/Pi?RMIT LNG PROJEM MECHANICAL
BUILDING PROh:IT IDP„Y114'ICA
DING ADDRESS.
2 03-3 6 IN �1 `Y\OC OI ✓\ �� G�Q UNIT# LDfp
'ARCI{f(E�'fN L`.CVi-�-ate I.ICNS9-OQg
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ADDRESS
I'lS\J•❑ S
Will the applicant or tutu. building occupaot store or handle hazardous material
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as defined by the Cupcnlnn Municipal Code, Chapter 9. L!, and the Health and Safety
SOLI S FEE
CONTACT: PHONE,:
QTY. ELECTRIC PERMIT
Ge®r f ((y 52\ O3y
Will the upplicamorfumre building occupant use eyulpmealmdevlccs whiehemit
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PERMIT ISSUANCE
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LICENSED CONTRACTOR'S DECLARATION
APPLIANCES - RESIDENTIAL
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Ihereby off n that l am licensed underproviaionsof Chapter9(commencing with
FEE
�00
Stain )of Dlv,umn3ofthe Business uftdyrvfaSsipgs\oma•"d�Ylianse is in
PANELS
tole eand cUect.
UPT0200AMP5
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m Qy
Daren c Comrnaor . Ste„ r
201 - 1000 AMPS
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ARCHITECTS DECLARATION
OVER 1000 AMPS I
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l understand my plans shall be used as public records.
PIn t: Wi
SIGNS ELECTRICAL
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Licenxd Professional
K tal6
OWNER -BUILDER DECLARATION
SPECIAL CIRCUITIMISC.
KOiO
1 hereby affirm that I am exempt from the Contractors License Law for the
W 3 a y¢
Professions Coy city or county
following person. (Section 7031.5, Blue.. and Professde: An
TEMP. METER OR POLE INST.
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which requires u permit to construct, alter, improve, demolish, or repair any ettacmm
tz,
�a,
uires me applicant for such to file a signed statement
p000 its issuance, also rcypermit
rt
POWER DEVICES
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4
rsn ntr
that he is licensed pursuant to the provisioof the Cosecies License law (Chrpur
SWIMMING POOL ELECTRIC
0
9(cotmnencing with Section 70(10 of Division 3 of the Business and Professions Cods)
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of her he is exempt therefrom and the basis for the alleged exemption. Any violation of
OUTLETS -SWITCHES-FIXTURES
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Section 7031.5 by soy applies., for apermit sirbamidae it,licnno a civil penalty of
52a0
notmmc than five hundred dollars($500).
NEWRESIDENTIALELECTR SQ.FT.
Wim
❑ M1eirsole compcnainea,
wrk.adthesomeonrmyemnended
tYi.
roffemadfor as
othe a
and the awcturtiactot isodense
and Prthewmk.
License Law cea not apply to an owner of
and Code: The Contractor's La does of apply toan.wner of
erty who orimproves lh and es such k himulfor through his
eny whnes,
prelds
improvementsinuend or If,
own employees,providedt mprovemen s m
mofferedforsale.
provehimpmvememsoatoatieaofc weer-
howcvcp the building nr improvement is told within one year or
'TOTAL.
omm a for pure
improve
builder soil I hove the burden of proving Chap M1e die not build or improve for puryose of
sale')'
QTY. PLUMBING PERMIT
❑ 1. as owner of the properly, um exclusively contracting with licensed contractors to
entrance, he project (Sec. 7U44, Brameas and Professions Cade:) The Contractors
LicenuUwdocsnotapplyw nownerofpropcnywhobuildsmimproves Ne ,and
PERMIT ISSUANCE
,hot .... met, bo such projects with a conumeam(O licensee pursuant mthe Co rporwo's
ALTER - DRAIN & VENT - WA'I'17R IFA)
License Law.
❑ 1 am exempt undo Sec. . B & P C for this reason
BACK FLOW PROTECT. DEVICE
Owner Date
DRAINS- FLUOR, ROOF. AREA, COND.
WORKMAN COMPENSATION DECLARATION
❑ Iherehy affirm thutJ have ucenifeme of amuse msdf-insure, oracertifcam of
FIXTURES - PER TRAP
WorkersCumpensatin t Insurance -a cenifted copy themcf(Sec. 380, Lab C.) which
all pl.y's under this permit.
Polin emce
p
GAS - EA. SYSTEM.I INC. 4 OUTLETS
y
Company
GAS - EA. SYSTEM OVER 4 (EA)
❑ t7wified copy is hereby furnished.
❑ Cenifee copy is fled with the city inspcainn diviaian.
GREASIVINDUSTRI, WASTE INTERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS'
GR BASE TRAP
COMPENSATION INSURANCE
(This section need not be completed if me Permit s for one hundred dollars($100)
SEWER - SANITARY - ST ORM HA. 200FT.
or leas.)
I comfy that in the performance of the work for which this permit is issued, l shall
WATER I IHATF.R WNTNTIELECTR
not employ any person in any manner an as to become subject to the Workers'
Compensation laws of California. Dam
WATER SYSTEM?RFATING
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Applicant
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NOTICE TO APPLICANT if,rfe, making this Cerdficam of Exemption, you should
NEWRFSIDFNTIALPLMtl. SQ. F1'.
become subject to the Worker's Compensation provision of the labor Cede, you mon
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forthwith comply with such proemm-u this pard, shall W deemed revoked.
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CONSTRUCTION LENDING AGENCY
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I hereby affirm Chet there is a coushostion lending agency for the performance of
TOTAL
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the work for which this permit is issued (Ser. 3197, Civ. QU.
Lender's Name
F
Leadvea Address
QTY. MECHANICAL PERMIT
0 U
I venify that I have mW this application and scam that the above lnformadon is
correct. I agree to comply with all city and county ordinances and state laws relating to
PERMIT ISSUANCE
E-' N
bui 11 const/ action and hereby amssairs, rcpresenutivexof this city to enter upon the
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so a,ed pmpecry for inspection purposes.
ALTER OR ADD TO MECH.
(W agree to save, indemnify and keep less the City of Cupertino//////gains,
liabil" ,Jndgmenm, soaps and expenscsuv' h yinanyway uee�st�ri�S{y
AIR HANDLING UNIT (10 IO.WICFM)
^e thrs perm //((nnjj
ACRIANDLING UNIT (OVER IO,IIOD CFMI
HAZARDOUS MATERIALS DISCLOSURI '
HEATING UNIT' (1'0 I(I(I,” BTU)
Will the applicant or tutu. building occupaot store or handle hazardous material
HEATING UNIT (OVER 1W." BTU)
as defined by the Cupcnlnn Municipal Code, Chapter 9. L!, and the Health and Safety
SOLI S FEE
Code, Section 25532m)7
❑ Yea ❑ No
VENTILATION 17AN (SINGLE RESID)
BOILER- COME THE OR 10.0(111 BTU)
Will the upplicamorfumre building occupant use eyulpmealmdevlccs whiehemit
hazardous air conterminous as defned by the Bay Arae Air Qualipy Marnagement
BOILER - COME (OVER 100.003 BTU)
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❑ Yes ❑ No
NEW RESIDENTIAL MECfI. 1Q. F4.
1 have and he hazardous mamriaE reyuirtmcma under Chapter the
FEE
erst rd
& Safcur Crile, Sermons 255115, 25533 and 25534. I unJerscand that
California Ing
o the
if the buildingecesnotmnt,whave amoans, thatitis my
does
istarmsibil. enotify
recupmp of ,M1e reyuir menta which most be met prim to issaunm of a Cenifeam of
Occupancy.
Owner or authorized agent Darr.
TOTAL:
FEE
261151
❑ 1
BUILDING PERMIT INFO
aBLLDt�G ELECT PLUMB MECH
LP ❑ ❑ ❑
ALED IN
11APUTER
FEE - FLOODZONE 11
FEESUMMARY
OUTSIDE FEP_
SANITARY Y
Rf:CE1Pl'a
SCI{OOLTAX Y
D
OKI 8199 J
PLANCHF.CK FEE
GRADING FEE
SOLI S FEE
ENERGY FIiE
PAID
as N g
TCHAL:
BUILDFNG EEE
SEISMIC ME
ELECTRIC PER
FEE
PLUMBING FEE
MECHANICAL M -E
CONSTRUCf10NTA
PAID /
D
OKI 8199 J