26340 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBtTuI1G-ELh. IRI AL PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 26340
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
1-1 ILDING ADDRESS: SAN I'rARY NO. APFLICA'nONSUHM^�H7AL DATE
/09/5 C/j0�c] 'f L-0)re S;r4pr&NIT# LOT#
NE AME;
i9��7�fe PHONE: CO CPOR'S NAME: NO:LIC NO:YDUN� � h � l•
N/C CONTROI.N
141RCHI LIC NO: y
DR .S: ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
S
61 PERMIT
pa PLUMB MECH
PERMIT ISSUANCE: El El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIALJOB D'l IOLt N
I hereby affirm that l an licensed under provisions ofarpor9(commencing with
+100 Scomm 7000)old,slon Sof the Bromessond Professions Cede,and my license is In PANP.LS
ty W full force and effect.
Fjly License Class Lic.# UPT02WAMPS
ryQa Date Combustion- 201-1000 AMPS
1- NARCHITECTS DECIARATION SQ,FT.FLOOR ARBA $/SQ.FT.
Z O N OVER!"AMPS
CZ-0
I understand my plans shall he used a public records.
Py w SIGNS ELECTRICAL
Zg�,,,I Liecord Professional OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
X0c. I hereby affirm that 1 am exempt from the Contractor's LicenseIsw for the
w3LLvE-i following rw-I.(Stal7031.5,Business and professions Cale:Any city.,county TEMP.MERR OR POLE INST.
11--x'0; which requires a permit to construct,alter.improve,demolish,or repair any structure
}� prior w its issuance,also requires the applicant forsuch permit to file a signed statement POWER DEVICES
W <C) than he is Necrosed turnaround to the provisions of the Contractor's License Law(Chapter
SWIMMING POOL fil.liCfRIC ` l
m o 9(commencing with Section 7000)of Division 3 of the lsusiness and R.frod scale) V LU ION
,-Z>- Section 7131.5 by anyaptherefrom and me moisfonhects thedcncmpti to civiny l Penalty
of DID LETS-SWITCHES-FIXTURES
FZQ Section than FY anyinalicnntfor Ipmmit subjects the applicant to civil penalty of
non mom than five hundred dollars(Sem).
�Fo ❑ I,asowncroftheprolxny,ormyempl.yeeswinh wagaasdtcirsol<wmpcnsadon, NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
W3= willdo the work,and the structure lsme intended artificial for sale(See.0044.Business
and Professions CMe:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,Sod who dues such work himself nr Ihnmgh his
emplayres,provided that such improvements are notimmmdedoroffered formic.If, OCC.GROUT' RES.USE IS
however,the buildingor improvement is sold within one yearofc.mpletion,the owner- A
builder will have nhe burden of proving that he did not build or improve for purpose of
's''le')' QTY. PLUMBING PERMIT FEE ROOD ZONE APN
❑ Las owner ofthe properly,stn exclusivelycontresting with licensed contractors to
Linstruct the project(Sec.]004,Business and Professi.ns Code:)The Contracm[s
icense Law docs not apply to an ownerofproperty who builds o,improves thereon,and PERMIT ISSUANCE
who contracts for such projects with o contractor(s)licensed pursuanuo the Contractor's T[R-DRAIN&V -WA FA
License Law. AL ( > FEESUMMARY
❑ 1 am exempt under See. .B&P C for this mason BACK RO OTECT.DEVICE. OUTSIDE FEES
SANITARY Y N
Owner Date D S-FLOORROOFAREACON RECEIPT#
199111— , . ,
IO
WORKMAN COMPENSATION DECLARATN SCHOOL TAX YN
❑ Thereby affirm mmlhnveacenifemc of consenuo self-insure,ore cenifcate of FIXTURES-PERT RAV RECEIPT#
Workers'Compensation Insurance or a certified copy thereor(Sec.3800.Lam C.)whi PARK ME Y N
rsall employee's uaderthisp.I,. GAS-EA.SYS M-IINC.4OUTLETS RLCLIPfp
Poolicyg BUILDING UIVISI F
Company W-FA\SWA OVER 4( ) PLANCHECK FEE
❑ Cenifed copy is hereby famished.
❑ Clarified copy is filed with the city inspection division. GREA S1 RE.WA I RCE GRADING TLE
CERIIIFICATE OF EXEMPTION FROM WORKERS' C STRAP SOUS PEIi
COMPENSATION INSURANCE,
(This section noted not be completed time permit is fa ane hund,Mdollars(51 y ,WER- ANY-STOR EA.2001717. ENERGY ME
or IcssJ
I certifynhat in the performance of eche work for which this rounit is issued.l shall W HEATER WNLECTR
not employ any person in any manna so as to become subject to the Workers' PAID
C.mpenamion Luwa of Cnlifomia. Date WAT'CRSYSMAf REATING Date Receipt#
0 Z Applicant
Z0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should NEW RESIDENTI LI'LM B. SQ.Pr. TOT
f^ ) become subject to the Workers Compensation provisions of the Labor Code,you must BUILDING FEF,
forthwith comply with such provisions or this permit shall b<decrned revoked. is
a (] CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm thauhere is a construction lending agency for the performance of
,7, 'TOTAL: ELIiCI'RIC IT
U 0 the work l in which this peon t is issued(Sec.3097.Civ.C.)
.. lender's Name PLUMBING FEE
F Lender's Address Q'IY. MECHANICAL PERMIT' FEE
U 1 certify that 1 have read this application and sure that the above information is MECHANICAL FEE
}' 0S correct. l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
F" y holding construction,and hereby aothoriu reprermatives.fthis city to enter upon the CONSTRUCTIONTAX
Vabove-ramooned pw,wo,for insperi.so purposes. ALTER OR ADD TO MECH.
(We)agree to save,indnnai ly and keep hwmleas the City of Catania.against
liabilities,judgments,costs and expenses which may in my way accrue against said City AIR HANDLING UN11(TO 10.000 CI:M)
n. donee ufrhe granting of this smut.
S3 AIR HANDLING UNIT(OVER 10.000 CFM)
Signan res ApplicanUC.mmctor Dat EXHAUST HOOD(WMUCn PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT HTO 100,000 BTU) Date Receipt#
Will the applicant or future building occupanlstorc or handle hazardous material HEA TING UNIT(OVER 100,)BB BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cede,Section 35532m)? VENTILATION FAN(SINGLE RESIDE
❑Yes ❑No
ISSUANC6DATE ,y
Will the applicant or fumrebuilAingoLosec uip
emordcviceswhichcmin BOILER-COMP(JHPOR &,000 BTU
haeuNom air unwninwu ns Jcincd by he gV C
Bay Arco Air Quality Management BOILER-COMP(OVER 100,001)BTU) (Jct
Diatr m? AY 1 (�
So
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. ( 1JI14
\\ I have read he hassrdrum materials requi¢mems under Chapter 6.95.f the Cllr v/nJJ-�f
iftheuilding dh&Safcur Calhave onsant,tht it is mresponi Idndemond that V
If the low building a doesnot
mentacurrently have a tenant,that it is my responsibility a notify the V
occupant nl the requirements which must M1c met prior m issuance of a Certificate of
Occupancy.
Owner or authodxed agent Date TOTAL: ISSUED BY:
OFFICE