26838 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELF, IRl AL Pufdrr NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL /�[S O Q
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION GvQ o
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
/p 55 d L L� n e
UNITN LOTN
OW MS NAME PHONE: CONTRACTOR'S NAME: LIC NO:
NAC
(///' CONTROLN
RCUUU'CFAHNGINEER: LIC NO: ADDRESS: ❑
:oNTACT: PHONE: QTY. ELECTRIC PERMIT F[?F-
BUILDING PERMIT INFO
�I
-253-2.-7Y
� 'jCH
253-2.7 ((/ PERMIT ISSUANCE LDG ELECT PLUMB ME1:1 El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES.RESIDENTIAL COR DESCRIPTION
CZ I herebyeflirtn that lam licensed underprovisiomofChipler9(cm
omencing with
E0E futull fon7Wl0 of Division 3ofthe Nosiness and prafessianx Cade,and my license is in PANELS ��
p License
e and Class face UPT02MAMPS
6Z License Class Lic.p
VF=a Dale Conn.., 201-1000AMPS SQ.fT.FLOOR AREA S/SQ.PT.
F-yZ ARCHTTF.CTS DECLARATION
ZO Z y 1 ondc.tvnd my plans shall be used as public records. OVER 1000 AMPS
rat � SIGNS ELECTRICAL
Q Licensed Professional
oofE OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XOaF I hereby affirm that I tan exempt from the Contractor's License law far rhe
IA3u.N following examn.(S<nion 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
F Y.O¢ which requires a permit to contact,alter,improve,demolish.or repair any structure
NYE prior to its issuance,also requite the applicant forsuch permit m file a signed statement POWER DEVICES
,ILL O that he is licensed purmantto the provisions of the Comma a''s License Law(Chapter
0.0 9(comer.6ng with Section 7000)of Division 3 of the Business end profession,Code) SWIMMING POOL ELECTRIC VALUATION
sedan, or that he is exempt therefrom and the basis for the alleged exemption.Any violation of
I:R< Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of OUTLETS-SWITCHES-FIXTURES
7H t more that five hundred doll..(5500). NEW RESIDENTIAL ELECTR Q.Ff. STORIES TYPE CONSTRUCTION
Wm I,as ownerofthe property,many employees with wages as theirsole compensation,
L _ s�ill do the wa,k,..d the structure is not imendcdoro!fated fersele(Sm.7040 Business
and Professions Code:The Contractors License Law does not apply to an owner of
property who huildsor improvesificasn,and whodoes such work himselforthrough bis OCC.GROUP RES.UNITS
employers,providedflunmch improvementsarenotintmals][ roffemdfa...le.If,
however,the buildingor improvement is wld within oneyearcefcomplerion,the owner-
builder ,will have the burden m(proving that he did not build or improve for u TOTAL:
pmvi B p p rpau of
❑
[J
I,so,ownendthe property.amcadusivelycOnwcting withlicensedconwnn.to MY PLUMBING PERMIT FEE FLOOD ZONE APN
reasbact the project(Sec.7044.Business and Professions Code:)The Contractor's
License Lawdecs not apply to an ownerofpropeny whomildsorimproves thereon,and P17RMIT ISSUANCE
who contracts forsuch projects with acomractor(s)licensed pursuant tothe Contractor's ALTER.GRAIN (RA)License Law. FEE SUMMARY
❑ I.m exempt under Sec. ,H&P C for this moon BACKFLOW PROTECT.DEVICE 'IDs ES
SANITARY YN
Owner Date RECF.IPTp
DRAINS-FLOOR,ftOOP.AREA.COND.
WORKMAN COMPENSATIONcomentCLARATION SCHOOLTAX Y—N-
1
N
❑ irs reby Compensation
th,lhave a urance or acereofcopytheood(See.te,o.Lim C.) hickto of Ir,%TURCS-PER TRAP RECEIPT#
Workers'Compensntionlrmurance oracenifiedcopy thereof(See 3gfN).Lab CJ which PARK FEE Y N
covers all employee's under this permit GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT p
Policy N BUILDING DIVISION FEES
Company GAS-EA.SYSTEM OVER 4(EA) PLANCIIECK FEE
❑ Cenificdeapykinmebyfumished.
❑ Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed if Ne permit is for one hundred dollars C$1000 SEWER-SANITARY-STORM EA.200FT. ENERGY FTE
orleas.)
I certify that in the Performance ofthe work for which this permit is issued,l shall WATER HEATER W/VENT/ELECIB
not employ any Person any manner so as to become subject to the Workers' PAID
Compens,imi LevO.f Califomia Date WA'ITR SYSTEMITREATING (late Receipt#
Q z Applicant
z 0 NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
F-' Vt become subject n the Worker's Compensation Provisions of the Labor Cade,you must
� ? forthwith comply with such provisions or this permit shall he deemed revoked. BUILDING FEE
Z
CONSTRUCT ION LENDING AGENCY SEISMIC ITH
I hereby affirm that there is a conabumion lending agency for the performance of
U O the work for which this permit is issued(Sec.3097.Civ.C.) TOTAL: ELECTRIC FEE
Lender's Name
OF Landers Address QTY. MECHANICAL PERMIT' IEE PLUMBING FEE
U 1 unify that 1 have read this application and sum that the above information is
>" 0. correct.I agree to comply with all city and county ordinances and stain laws relating to PERMITISSUANCE MECHANICAL FEE
�-' Inildingconsirunion,and hereby.mhoriaonepmaenmtiveaof this city to enter No the CONSTRUCTION TAX
U .hove-mentioned property for inspectionPurposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify unit keep harmless the City of Cupertino against
liabilities judgmcm,costs and expenses which may in any way same against saidCity AIR HANDLING UNIT(TO 10,000 CFM)
in cmtseque999ggp��gof thelium, oft ' permit.
/,/ O/(A AIR HANDLMG UNIT(OVER 10,001 CFM)
Signa / Applicant/C' onuactor `lI/,I Data EXHAUST HOOD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I00,000 BTU) Dam Receipt#
Will the applicant or future building accept,store or handle hmardom material
u dented by the Cupertino Municipal Cade,Chapter 9.12.and the Health and Safety IIFATING UNIT(OVER 100,000 BTU)
Code,Section 25532ho?
iP
❑Yes ❑No VENTILATION PAN(SINGLE RID)
BOILER-COMP QHP OR 100,000 BTU) �IISSUANCE DATE
Wi1lthm,pPlicumorfm�rebuilAingoecuPunmseequipmenmrdeviceswhich emit N Ll n
hua,dous air contaminants us defined by the Bay Area Air Quality Management BOILER-COMP(OVER I00,Wo 0 BTU) t 7
District?
❑Yea ❑No NEW RESIDENTIAL.MECH. SQ.FT. is��/a p
1 have need the ha.mdem m,eriuls requfmnems under Chapter 6.95 of the Cq l. 199
Culifer is Health&Safety Code,Sections 25505,25533 and 25534. 1 understand the, trt
Ethic building does not cumemly have u tenant,that it is my responsibility to notify the (y/- V Ur
occupant of the requirements which must he to Prior to issuance of a Crmficam of �Njjl�u
Occupancy. ___
Owner m i uthorixed agent Dam TOTAL: ISSUED BY:
OFFICE
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