26860 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO f ' y-)I' •' A PERMITNU.
APPLICATION/PERMIT PLUMBING.MECHANICAL
ItU11.U1NG DI VISION BUILDINE:PROJECr IDENTU9CAT10N;
BUILDING ADDRESS: SANITARY NO. APT•LICA'OONSUISMHTALUA '
LOT. ,_(VX
0% RS 'A IE: /1 raaa� ^ CONTRACT OR NAME: LIC NO: NiC CONTROL
1C131TLCIENGINLER: LIC NO: ADDRESS: El
CONTACT: PHONE: QTY.
TY t,YM1- ELECTRIC
PERMIT �'n� ^'�.;FCE;[';' BUILDING PERMIT INFO.
BLM ELECT PLUMB MECH
PERMIT ISSUANCE ,
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL IOtl U[SCRII'1']ON
]st cZ I hereby affirm that l notlicensed under provismasofalipter9(commeacingwith
-00 Section 7000)ofDamisian3 of the Business and Professions Colt my license is in PANELS
—t»- fall License
ClaJcffcn.
:WU UP TO 2(q AMPS
.Zw Dole
Class Contr
Q m Dam GOnlmaor 201-I WO AMPS E
�,Z ARCIII'fECI'S DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA ^ EISQ�FT.
lundersand in, [..,,but]the used as public records. �` `,•
SIGNS ELECTRICAL ff t -
�t,•j Licensed Promi,moul
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
Oi V I hereby affirm that 1 un exempt from the,Conmctor's License Law for the
followln (Section]031.5.Business and Pofessiors Code:Any cit moat 'TEMP.METER OR POLE INST. ) .�
_OQ gmawn. city Y 1,
whl<M1 requires n permit to construct,the alma,improve,demolish,or repair ed awcmm
3Ytprior to is issuance.also rcyuircs the applicant for such Permit rile asignrd summcnt POWER DEVICES
Y_0 that he is licensed pursuam to the provisions of the Contactors License law(Chepmr SWIMMING POOL ELECTRIC — VALUATION
�x Gk
9(commencing with Section)000D&Division 3 ofthe Business and Professions Coda) -;
,not, or that he is exempt therefrom and me basis for the alleged exemption.Any violation of EIS-SWITCHES-FIXTURES
_Z} Section 7031.5 by any applicant for u permit subjects the applicamm a civil penalty of
=� not more thanfive hundmd dollars(5500)' NEWRESLDENTIALELECIR _SQ.FT. STORIES TYPE CONSTRUCTION
;F. ❑ Lamwnerof thepropeny,ormycmploY«switM1 wagesu thcirsolecompensaiton,
y 3.2 will do the work.and the structure is net moundedo offcmd for sale(Sec.Jp44,Business
and Profc omps Code:The Contractors License law does not apply ro an owner of
property who builds or improves themom,and who d«s such work himself or through his
OCC GROUP RES.UNITS
assocroployecs.providedthat such improvementsart not mended-offered farrole.If,
hnwevewillhavlhe burden
improvement ishin hewithinioneywr of completion,the.ostipurpol of
builder will have rite buN<n of proving that he did not build onmprove for puryosc of _
Y
saleYl,.s owner afthc n Ycon gw QTY.i+u; I e PLUMBING PERMIT n �+. �:.}�FEEF;j FLOOD ZONE APN
❑ prop, Y.am ex,luuvel uvan thl censW conuanorsm rt'_r'�, fY.ret.. ;,rse.Hm
instruct the pmj«t(Sec.Rau,Business and Professions Code:)The Convaomrs
License Lawdos nor pply roan ownerofpnopimy whobuildher improvesda eon.and PERMIT ISSUANCE
whocontraasfor such projects with aconmactims)licensed pursuant oche Conuanor's - v
License law. ALTER-GRAIN&VENT-WATER(EA) ?(n,:Q fyy�f rt_. FEE SUMMARY�'j�j..-y,Sdjy i:.cI
❑ 1 am exempt under Sec. ,B&P C for this won OUTSIDE Ft
ES
BACK FLOW PROTECT.DEVICE
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ IherebyaffimUha l have acenificae ofeement to sclf-insute.oraartificateof p�.pUgpS-p�.�p RECEIPTp
.lVoderi Campcnsation Insurance orucenified copy Ncrcof(5«.3800,Iab C.)which PARK FEE Y N
O
covers all employee's under this Permit GAS-EA.SYSTEM-I INC.4 0UTLETS RECEIPT
policy p BUILDING DIVISION
FEES
Company GAS-EA.SYSTEM-OVER 4EA) PLANCHECK FEE
❑ Cmified copy is hereby famished.
❑ Cenified copy is fled with the city inspection division. GREASMNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This senior n«dam be completed iftbe permit is foram,hundred dollars($HXU SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the performance of the work for which this permit is issued,l shall WATER HEATER WfVENT/ELECfR
not employ any person in any manner so as to become subject to the Worked PAID
Compensationlawsof Califomm. Dam WATER SYSTEMMU1ATING Date Receipt#
z Applicant
NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
e 7) NOTICE
saOAPo me WoT:If,after Compensation
this sision of of Labor ode,You must
— fA become tit,Workers Compensation pr it shall be the Labor revoked. must BUILDING FEE
� > forthwith comply with such provisions or this cantor shall be dttmed invoked.
a CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z 1 hereby affirm that hem is a conswctiom lending agency for Ne perfomtance of TOTAL: ELECTRIC FEE
O the wad far which this permit is issued(sec.3091,Civ.C.)
Lender's Name s'eu �'w,'s; »" "' - n tx PLUMBING FEE
F 1<nacr,Address QTY.!'.j,',Z �MECHAMCAL'PERMIT, "',rc ;'FEE'^'�
V I certify that I have mad his application and ante than the above information is - " MECHANICAL FEE
come,,I agree to comply with all city and county norounces and sum lawsrelating PERMIT ISSUANCE
0.0. building construction,and hereby authorize teprescnuoves ofthis citytoc CONSTRUCTION TAX
z above mentioned propeny for inspection puryoses. a ALTER OR ADD TO MECI I.
—� pVe)aF o save,indemnify wd k«p harmless the City of Cu v
I! ilitiesg ns.mas anJ eswhichmayi YwaY¢
comau, d it, LING UNIT(TO 10.00(l
on qucn ofthegra LLLLLL A rANDLING UNIT(OVER 10.Igq CPSU
Slgue rcofA i, r Dole 4AUST HOOD(WMUCr) PAID
HAZARDOUS MATERIALS DISCLOSURE HEA TING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant orfumrc building occupant atom or handle hazardous mamda HEATING UNIT(OVER IW.IXIO BTU) TOTAL-:
ns defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(#)?
❑Yn ❑No VENTILATION FAN(SINGLE R[SID)
ISSUANCE DATE
Will theupplicantorfuturebuiWlnFuccupant use equipment ordeviceswbich emit BOILER-COMP(3HP OR IN."BTU)
hazardous air contaminants as defined by the Bay Am Air Quality Management BOILER-COMP(OVER 100,000 BTU)tai
1 AUG d V r`
1 is ri ❑Yee ❑No NEW RESIDENTIAL MF,CH. SQ.Fr. 1994
1 have mad the hazardous materials requiremcns under Chapter 6.95 of me
Califomia Health&Safety Cole Sections 25505.25533 and 25534. 1 understand that
if the building dos not carenny have a tenant,that it is my responsibility to notify the
rcupam of Ne mquirememv which man Ixe con prior
to issuance of o Cenificute of
Occupancy. .
Owner or umburimd.,cut Dale TOTAL: ISSUED BY:
OFFIC