26032 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINOUJIMiNG--ELECTRICAL PI;lUdirNO.
APPLICATION/PERMIT PLUMB INC,-MECHANICAL X� 0 LA
BUILDING DIVISION BUILDING PROJECT'IDEN'PIF'ICA'1'ION G
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
S/ UNIT# LOTX 1- 19- 941
OWNE SNA i PHONE: CO RACI RISNAME: LIC NO:
• —Q /0 _2 NIC CONT'ROL11
ARC TIiCT/ENGINF.ER: IC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT PEF-
BLDG ELECT PLUMB MECH
O Y PERMIT ISSUANCE ❑ El `GYl El
LICENSED CONTRACT OR:S DECLARATION APPLIANCES-RESIDENTIAL �I
M=Z Iheebm Wat
yaffrl am licensed under proskionamChapter9(commencing with )OB DESCRIPI ION
P02 Section 70M)of Division 3 of the Business and Professions Code.unit my liana is in PANELS
z full fume and if
t.
FOw _C 3�_ UPTG2MAMPS
/W Liccncc Lic.p
m=y Dae Contractor 201-I(NIUAMPS SQ.FT.FLOOR AREA S/SQ.I'I'.
ZOyr' R fI1TELTS DECLA0.ATION- OVER IM AMPS
O Z—❑ I understand my plans shall be used as public record. II;f-
E;,y�; SIGNS ELECTRICAL
A L E
Q Lirrnv d Professional - n
X0" OWNER-BUILDERDECLARATIONSPECIAL CIRCUM'/MISC. Y ^ p
Op, I hereby affirm Wa 1 am exempt from the Contractor's License law for We IIIA P U
m3m,; followin,...(Section 7031.5.Business and Profession.Cade Anycityarembity TEMP.METER OR POLE INST.
F IT R
V-OQ which requires a Benoit tomnu .1m,cac6 almimprove,demolish,or trim,any etmmurt -
Syy�} prior ni its omance.also requires the applicant for such permit f le a signed statement POWER DEVICES DAr
G
d C G O that he is licensed pursuant the provisions of the Contractor's License Law(Chapter G
tidxOo F' 9(commencing with Section 9gp)of Division 3 of the Business and Professions Code) SWIMMING POOL(ELECTRIC VALUATION
W_y or that he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
Z Q Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of
INImtnmre than five to ],ad dollars(SIM). NBW RISIUEN'I'IAI.BLECfH S .IPI'.
IN E] L asowneroftheprop rty,nrmyemployecswithwagesustheirsolecompe^sation. Q S"I ORIES TYPECONSTRUGHON
y3=e will do the work,and the structure is not intended or offered for sale(See.7044,Business -
and Professions Cale:The Commetors License law does not apply to on owner of
property whobuilds or improves lhemon,and whodeas such work himselforthroughhis
employees,provided fica,ach iin,ovememcnre nor tordedaroffeed forsale.If,
OCC GROUP RES.UNITS
however,the building or improvement is sold within one yearofcompletion,the owner- TOTAL:
builder will have the buNen of proving that he did not build or improve for purpose of
ia1e.). QTY. PLUMBING PERMIT PEE PROD ZONE APN
m
❑ 1,to owner ofdhe property,am exclusively contracting with licensed c^ntaors to
construct the proja:t(See.9044,Business and Profession,Code)The Contractor's
License Lawdoes not apply to an^wnerofpropony who builds orimprovesdareoq and PERM]'1'ISSUANCIi
whocmtmcB forsuch pmjects wiW u conuactor(s)licensed pursuant tothe Contractor's
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt kinder Sec. .11&P C for this reason O SDE FEES
BACK BLOW PROI'IECI'.DEVICEOUT
YN
Owner Data DRAINS-FLOOR.ROOF.AREA,COND. RIECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTA% Y N
• ❑ I hereby affirm that l have a certificate mconscnno sel6insure,at a certificate of FIXTURES-PER TRAP RECEIPT#
Worker'Compensntion hicumme or a certified copy thuurf(See.3800,Luh C.)which PARK HE Y N
RECEIPT#
en,all em der this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS BUILDING DIVISION FEES
Policy: &;Ido
ComrynY 4 L 1 Q6 GAS.PA.SYSTEM-OVER4 BA) PLANCHECK FEE
❑ Candied copy is hereby Tum a city
i� CenifiN copy is filed with theeityi^.cpection division. GREASG/INDUSTNL WAS'fEINTERCF.PfOR GRADING Pili
r
CER'I'IFICATF.OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
illbbsecti^n need not becompleted if the Permit is for one hundred dolears(SIM) SEWER-SANITARY-STORM FA.200FT. ENERGY FBE
kir lass.)
I certify that in the performance of the work for which this permit i.issued.)shall WATER U EATER WNENT'/ELECTR . SO
not employ any person in any manner sin as to become adjamt to the Workers' PAID
Compimadionla,sof Califomio. Date WATER SYSTEM/TREATING Data Receipt#
OZ Applicant
0 NOI'ICE TO APPLICANT:qufmr makingthis C,r ificamof Exemption. no should NEW RESIDENTIAL PLMB. SQ.IT. TOTAL:
0 become mbjecuo tire Wmker's Compensation provisions of the Labor Code.you must
7 forthwith comply with such provisions o,,his armit shall be dammed.,.kid.
BUILDING FEE
L1a Q CONSTRUCTION LENDING AGENCY SEISMIC ME
z Ihereby affirm that there is it construction lending agency for the Performance of TOTAL: S Ii1.l.CfRIC FlEIi
V O We work far which this pe.it is issued(Sec.3057,Co.C.)
Lmlcr's Name
OF Lenders Address QTY. MECHANICAL PERMIT F'EE PLUMBING PEE
Z .
O U I ranify Wal 1 have read this applicaion and start thus the move infommtion is
P-I
correct. l agree to comply withall city and county ordinances
and state laws relating to PERMIT ISSUANCEMECHANICAL PEE,
F" building construction,and hereby audaudie represenmtivesofthis city to enter upon We CONSTRUCTION TAX
U Z abovotmmio^ed property far inspection parsecs. ALTERORADUTOMECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
haladities,judgmems.costs and expenseswbich may in any way accrue against aid City AIR HANDLING UNIT(TO 10,000 CFM)
rea{uamcsol diagraming fdhop it.
AIR HANDLING UNIT(OVER 10.000 CFM)
natuerre of AppllcContmelor Date EXHAUST HOOD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 B'IU) Dude Receipt#
Will the applicant or future building occupant store or handle haaardom materiae HEATING UNIT(OVER[BLOW ETV) TOTAL:
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safe,,
Crda Section 25532(a)? VENTILATION PAN(SINGLE RESID) a S0
IDYes 1:1 No
ISSUANCE DATE
Will Weapplicamorfmure building occuWm use equipme^tordeviceawhichemit BOILIER-COME(311P OR 100,000 BTU)
Imeallous air contaminants as defined by the Bay Area Air Quality Management BOIL tER-COMP(OVER 100,M)BTU)
District?
❑Yes ❑No NEW RESIDENTIAL.MECH.—SQ.I'1'. P /1
p '
1 have mad the haurd^us mammid,rexcitements under Chapter 6.95 of the
California Health&Safety Crede.Sections 25505,25533 and 25534.I understand Wal JAA� 1
if We building dues not currently have,tenant,thin id is my responsibility m ria By We ••
occupant of the ric,docniams which must he met prior m issuance of a Cenifiaotc of 9 199A
1.7 A
ca.'emy.
CI IY U1 ,t -
Owner kir amhorincd,gem Date TOTAL: ISSUED BY:
OFFIC