26249 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO . IN(:TRLRCTRI ' , PERMIT NO.
APPLICATION/PERMIT PLUSBBNG-MECHANICAL �`�] /I (1
.,
BUILDING DIVISION BUILDING PROJF.Cr IDENI'IFICAI']ON v G 4 J
BUILDING ADD BSS: SANI'T'ARY NO. APPLICATIONSUBMI"1TALDAIIi
e UNITLTa OT a
O ONE: R
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R
7/ NTRvOLR% d
)�ARCHITI,C`UENGINEER: k LIC NO: ADDRESS: ❑
/ COM1TACI': �
PH NE ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB M[C
PERMIT ISSUANCE ❑ -
I,ICENSED CONTRACTORS DFCLARAI'ION APPLIANCES-RESIDENTIAL
no:z I hereby affirmthet l em lic,awalmderprovisionsofChapto 9(commcncing with JOB DESCRI ON
to 00 Section 7")of Divsion 3 fit Business an Cede and my licwu is in PANELS
�V1- full fore,undeffecc. ` ` /K.s"7e UP T0200 AMPS
FZ WVjy Licenu Clore 1ie.N
r <cy Date ContractorD 201-I"AMPS SQ,FT.FLOOR ARCA S/SQ.FT.
7ONy ARC111TNC1'S DF. .ARATION OVER 1000 AMPS
O Z�'D 1 under,mnd my plans shall he used as pathic records.
P n t ul SIGNS ELECTRICAL
<,��j Licensed Professional
ae ce< OWNER-BUILDER DECLARATION SPECIAL CIRCUHUMISC.
MO I hereby affirm chat 1 an exempt form the Contractor's License Law for the
l
".
following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST,
F LLJ Ow; which require,a permit u,construct,al¢q improve,demolish,or repair any structure
n
}7 pnoo its issuance.also requires the applicant for such permit o file a signed statement POWER DEVICES
w p that he is licensed pursuant ut do the provisions of clic Contractor's License Lew(Chapter SWIMMING POOL ELECTRIC'
12-_L 9(commencing with Section 7")of Division 3 of NC Business and Professiora Code) VALUATION
m Nat he is exempt therefrom and the basis for the alleged exemption.Any violaticnaf OI/TLE1'S-SWITCHES-FlXTURES
FZa Section 7031.5 by any applicant for a permit subjects the applicantto a civil penalty of
no
rc than five hundred dollar,D500)'
❑ l,asuwneroflhepropeny,ormyemployecswiihwagesastheirsolecompensation, NEW RESIDENTIAL ELLCfR —SQ.FT. 51' IES I'YPECO STRUCTION
y3- will do the work,and cheswcmre said irumdralm.ffered forsale(Sce.7014,Business
and Profcssime,Code:The Counselors License Law does not apply tp w owner of
properly w ho but Iris or improves Merton,not who dose such wart hinnel f or through hi s
own 1 e Provided that such improvements minteadedoroffned forsale.If, OCC.GROUP S. 1
amp r.th builaovr provemwithin n
huilder will
have
the
or improvement n ofproving
is sot a di in one year or improve fur the owner- T'O rnL:
Header will bave me namwmnravmg mel he red not nada or improve Tar pnryaae nr r
sale.). QTY. PLUMBING PERMIT FEE
❑ I,mowner ofthe propeny,em exclusively rontracting with licenxd contractunto ROOD ZONE APN
construct the project(Sec.1044,Business and Professions Cade:)The Convector's J
LicenseLewd«snolapply tow owncr,fpropeny whobuildsorimprovcsthercon,and PERMIT ISSUANCE
whocommms fmsuch projects with a contractors)licensed pursuant lolMContractor's ALTER-DRAIN&VENT-WATER(FA) ESU ARY
License Law.
❑ I m exempt under Sec. ,B&P C far this reason BACK ROW PROTECT.DEVICE SIDE PEES
a
SANITARY Y N
Owner Dare DRAINS-FLOOR,ROOF,AREA, RECEIPT
CompenWORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
� I hereby affirm that l have a cenifican,ofeonsent to self-insure,or a cienificateof FIXTURES-PER TRAP
XRECEI p
sation Insurance or a certified copy thereof(Sec.3800.LabC.)which PARK FRE Y N
r'.11 employee oder This,ermid: GASC p
A.SYSTEM. INC.INC.40UTLETS
Polley N Z BUIL NG DI SION PEES
`Colmpany - ;�y--Ry-Tran-Je.�.--rI — GAS-EA.SYSTEM-OVER4(EA) PLANCIIECK RE
�y
Cent,Me oris ' 'F`-e,V -,(0ev
❑ Certified copy is filed with Ne city inspection division. GREASE1INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS F1311:
COMPENSATION INSURANCE
(Thi,sectionaecalme be completed ifthc Permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200M. ENERGY PEE
or less.)
I cenifylhat in the perfom rc of the work for which Nis panni,is issued,I shall WATER HEALER W/VENT/ELECTR
not employ any person in any towner so m to became subject to the Worken' PAID
Compcnsatiou Lawsof Califmmia. Dale WATER SYSTEMMfiEATING Dale Receipt
Q z Applicant
z C) NOTICE.TO APPLICANT:If,after making this Certificate of Exemption,you should NEWRESIDENTIALPLMB. SQ.FT. TOTAL:
p: e, u
become subject the Workers Compeamdon previsions ofthe Labor Cade,you muse BUILDING FEE
04 D forthwith comply with such provisions or this permit shall be clamed revoked.
W F CONSTRUCTION LENDING AGENCY SEISMIC FEE
rtrtrtq""" 1 hereby affirm that them is a construction lending agency for the performance of
CT
U ,z ELERIC FEE0 the work for which this permh is issued(Sea 3097,Civ.CJ
Lender's Nwn,
Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE I
O U I rectify diet 1 have read this application and sum Nat the above information is MECHANICAL FEE
correct.lugrccmcomply with ell city wdcovmy oNinanccs andsmte laws relating. PERMIT ISSUANCE
F" N buildingeanuaruclinn,and hereby muhanzerepresental,"01Nis city loenterupen 11 CONSTRUCTIONTAX
U z above-mentioned N pcdy Ibr inspection purposes. ALTIiR OR ADD TO MF:CII.
(We)agree to save,indemnify and keep harmless the City of Capetian against
Iimilidics,judgmcros,msdsend expenses which may in any way accrue against said Cily AIR HANDLING UNITCI'0 MON CFM)
in comrxluence of the greening of this permit.
AIR HANDLING UNIT(OVER 10,0110 CFM)
Signamreof A,demiUCammemr Date EXHAUSTHOOD(W/DUCT, PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 10X1,000 BTU) ` Dale Receipt a
Will the applicant or furore building occupant store or handle hmarduus mmenal
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IM.W0 BTU) TOT L:
Code Section25532(ap VEND IfATION FAN(SINGLE RESID) C71� P5
11 Yes ❑No ISSUANCE,DATE
Will the applicant or future buddingoccupant uuequipund ordeviceswhich emit BOILER-COME(311P OR 100,000 BTU) pA�f6C
haewrlous air commitments as defined by the Bay Arca Air Quality Management BOILER-COME(OVER 100,000 BTU)
❑Yea ❑No NEW RESIDENTIAL MECH.—SQ.FT. @ 19
.e 1
1 have read the hazardous materials requirements under Chapter 15.95 of the 11� (h
California I leallh&Safety Code,Sections 25505,25533 and 25534. 1 understand that ��` R 1NV
if the building does no,currtmly have.tenant.that it is my responsibility to notify N,
occupant of the regmremcn ch mau"IIesmell pprriarr t rssoance of a cenifica¢.oaf V
a/ s1'. n� �'�` QQy 9-�il(,k-71/l./9J \Va1t�f��IF \1
Ov sTi�j�iAO L: ISSUED BY:
OFFICE