26767 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOIII'DJNtrRI'F.LTRTCXI. PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 26767
BUILDING.DIVISION BUILDING FR(11RCT IDEN'T'IFICATION
BUILDING ADDRESSS SANITARY NO. APPLICATTTONSUBMfITALDATE
/✓- /4 &O, IINITX I.OT0 rL� 4
OWN[
BS NAME: PHONE.: CONTRACTORS NAME: LIC NO: NYC CONTROLN
trr
�ARCHI'I'E '111.1 i LIC NO: ADDRESS: /I A — ST ❑
/f xI
CONTACT: PHONE:
�� //�J yy/ �J'
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
/YOrrna A 4✓�171/ PERMIT ISSUANCE 0 El
BLDG ELECT PLUMB ECH
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
n K'y I hereby affirm That l an licensed underpmvisions of Chaptm9(commencingwith
VJ 00 Section 71100)of Division 3 of the Busucl s and Professions Code,and my license is in PANELS
full force andcffe UPTO200AMPS rcevV�,
Q , License Lt.,g
y¢a Data Contmnor /
y ` 201-1(100 AMPS
Z.O,NZ ARCHI'I'ECI'S DECLARATION OVER ItXlO AMPS SQ.IT.FLOOR AREA 5/SQ.FT.
ppp I und<sound my plans Nall Is used m public records.
P 22 SIGNS ELECTRICAL
621 Licensed Professional
CC OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
x0.OyF 1 hereby affirm that 1 am exempt from the Committees License Law for the
W3Ooea following rensnn.(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST. ^ /�
�mJ which mquisu npetmino quires the pmgimprovcant for uchpen iit ore a signed
g any stmcturt i- / \, �-
�oe}o prior esscensedpalso sloth thevistuarodthe Commmino Licenc gLa statement POWER DEVICES
W C O p that he is licensed punuant to the provisions of the Camncmes License law(Chapter
o.qe� 9(cnmmencingwill,Section 7000)of Division 3 ofthe Business and Professions Cade) SWIMMING POOL ELECTRIC j r i y T
i�_,ce or that he is exempt therefrom and the basis for the alleged exemption.Any violabonof OUTLETS-SWITCHES-FIXTURES a,
4 Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of
t marc than five hundred dollen($500). .
C o nO I,asowncrofthepmp ny,ormyemploymswithwegnmtheirmlee mpemefion, NEW RESOLNTIAL ELEGIE —SQ TYPE. NSTRUCI'ION
y3e0 will do the work,and the structure is not intended oroffered fouale(Sec.7044,Business
and Professions Code:The Control License Law does not apply to an owner of
property,whobuildsorimprovod,erean,and whodoes such wort himselfonhrough his
employees,pmvidWthmarcnm
sochimprovementsintendedmofferedforule.if, OCC.GROUP RES.UNITS
however.the bulldingor improvement is sold within one year of coomefon.the owner.
bidder will have the burden of mein that Ill nm build or ice for TOTAL:
p g trove purpose of
ale.).
[II,mownerofthepropery,am exdusivdymnmening wid,licensed<onuenom to QTY. PLUMUING PERMIT FEEFl.00D ZONE, APN
construct the project(Sec.701 Business and Professions Cade:)The Contractors
Limme Law docs not pply u,an ownendpropeny whobtaildsorimprovesthereon,and PERMIT ISSUANCE
who con tracts O such pmjec is with a mmnctor(s)licensed pursuant to the Contractor s
License Law. ALTER-DRAIN&VENT-WATER(RA) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this ma n BACK FLOW PROTECT.DEVICE.
OUTSIDE FERS
SANITARY Y N
Owner Data RECFIPTk
DRAINS-FLOOR,ROOF,ARRA,GOND.
WORKMAN COMPFNSATIONDECIARATION SCHOOL TAX Y N
XIh by ffmrth Ins certificatetc a Ifcertificateich FIXTURES-PER TRAP RECHIPI'M
kerv'Cyngmpensetion Insurance oraceniliedcopy thereof(SeeuJBW,Leb CJ which PARK FEE Y N
oversPoI cy p 1/V plye's under.1Ai�pyrmit BUILDING DIVISION FEES
O` :,H U �f GAS-EA.SYSTEM-I INCAOUTLETS
Cn Pa^Y�YI7 n MIK ff<<rn ' GAS.EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
Carolled copy is here
Certified copy is filed with the city inspection division. OREASFANDUSTRL WASTE INTERCEPTOR GRADING MH
CERTIFICATE OF EXEMPTION PROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thia,mu.nneed nut blminploted ifthe permit is faro..buionxicdian Giffin SEWER-SANITARY-STORM F.A.200FT. ENERGY ITE
wills.)
I unify that in The performance of Ne work for which this permit is issued,Ishall WATER HEATER W/VENTIELF.CPR
not employ any .on in any manner an as in bmome aobject to she Worker' PAID
Compensation Laws of Califomia. Date WATER SYSTEMIGIRATING
z Date Receiptp
Q Atplicant
NOTICE TO APPLICANT:If,oftm making this Cenificemof Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
Vj become subject to the Wmkds Compensation pownionsofthe labor Cod..you must
forthwith comply with such provisions or this permit"I be deemed revoked. BUILDING FEF.
0. [� CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that Nem is a commmtian lending agency for the performance of
U O�+ the work for which Nis permit is issued(Sm.3097,Civ.C.) TOTAL: ELE(fiC ITE
F' Lender's Name PLUMBING FEE
O U Iandees Address QTY. MECHANICAL PERMIT FEE
1 minty that I have reed this application and state that the above information is MECHANICAL FEE
correct.I agree tocomply with 01 city and county ordinanem and Stam lows relating 0 PERMIT ISSUANCE
building construction,and hereby authorise represcrostivesofthis city in enter upon theCONSTRUCTION TAX
U z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Iiabilisies.judgmenu,aceta w,dextemm which may in any wayacemeegains,said City AIR I IANDLI NO UNITOO 111."CPM)
in consequence of the granting of this Permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of A,licanVClomeme Dam EXHAUST I IOOD(W/DUCT) PAID r
HAZARDOUS MAT17RIAM DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt p
Will the applicum or future building occupant alum or handle hazsrdous material HEATING UNIT(OVER IW,11(IO BTU) TO'T'AL'.
as definedpe
by the Cunino Municipal Code,Chapmr 9.12,and the Bmlth and Safety
Code.Section 25532(a)7
❑Yes AN.
VENTILATION FAN(SINGLE RPSID)
lISSIJp I E DATE
Will theapplicamorfmurcbuildingawopam use equipmemordeviceswhichemis BOILPE-COMP(JIIPOR 100,0100 BTU)
harsolous air contaminants or defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 160,000 BTU)
Divide? U/'Ae/lf1A
❑Yes XNo NEW RESIDT:NTIAI.MECfI. SQ.PI'. (6 2514 7na,a
1 have read the hazerdoos materials regeircmcnta under Chapter 6.95 of the p� Ay
California Health&Safety Code.Sections 25505,25533 and 25534.I understand that
i f the bui lding does not currently have a tenant,that it is my responsibility to notify the
Vr`Ur"rry
cup, t of the require to which must be met pdnr to issuance of a Ce ifc eat
De
Owerumhodzed agent ��� �� AL: ISSUEDBY: