26733 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CCPERTINO UILb1NC-RI:ECPRICA. PERMIT NO.
BUILDING OF C,n ERTry APPLICATION/PERMIT rLUMBINO-MECHANICAL 26733
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IIIJILIIIN(i PROJN:(Tr111EN'1'IFICA'I'ION L v 1 J J
BUILDING ADDRESS: SANITARY NO. AI/RLICAT N+S,aUB TTTAI.UA'1E
(lG , UNIT M LOT#
WNIiRS / G
OAME: PHONE: COMfRACfOR'SNAMF LIC NO:
01 4eaa _ N/C C NTROI.p
QCBIT- /ENGINI!ER: LIC O ADDRESS f�.r
G J 2+f ❑
CONTACT PHONE: th J " r '
PA9.sxE s�v xiP a ^
QTY, > ELECTRIC PFRM!Tj 6 x? FEE,' d+.?HUIUXNG PERMIT INFO
8k FlECT PLUMB
1PERMIT ISSUANCEsk> BLDG MEC
❑ ❑ ❑
LICENSED CONTRACTOR'SionsofDECLARATION APPLIANCES-RESIDEM'IAL JOB DESCRIPTION
Cy 1lacrebyadit70(Y)ofD ibwl3 ofth sed Basins pmvisifesions Code,
mmecensewith
�00 Senlon]lID(q of Divisinn3of the Business and Professions Code,coed my license is in PANELS
ty W F full farce and a t.
FZW License Clms. y��.w Lic.M 3y�3Gi UPTO200AMPS
v 6 so Dam Centmctor 201-1000 AMPS
7 FO
O vi Z.4 ARCHITECTS DECLARATION OVER IWO AMPS SQ FT.FLOOR AREA $/SQ.IT.
O Z q 1 understand my plans shall be used as public records.
y W. SIGNS ELECTRICAL
Q Y j Licensed Professional
�yo:6 OWNER-BUILDER DECLARATION SPECIAL CIRCUFDMISC.
KOyF I hereby affirm that I um exempt from the Canniness License Law far the ^
W31im following reason(Section 7031.5,[Justness and Professions Code:Any city or county 'TEMP.METER OR POLE INST.
F"p1 which requires a peradd I.emnstmct,ober,improve,demolish,or repair any structure I;J
}� pnono its issuance.also requires Thevpplicant formshpemdno file asigndstmement POWER DEVICES
NW Q p that he is licensed pursuant to the provisions of the Contractors License Law(Chapter t�
ayoff 9commencing with Section 7000)of Division 3 ofthe Businessand ProfessionsCede) SWIMMING POOL ELECTRIC 1 LU ION
iW—ver mnh:u he is exempnhcrefrom and the basis for the alleged exemption,Anyviolatinnof OUTLETS-SWITCHES-PI%liJ / 17,
tK, Section 7031.5 by any applicant for a permit subjects the epplicanno a civil penalty of ` • `� 9
T 0 not mare than Ove hundred dollars(55W). NEW RESIDENTIAL ELECIR
C o ❑ 1,asowneroflheprop M,ormyemployaswithwagesastheirselecompenmdon, — STORIES TYPE CONSTRUCTION
will do the work,nnd lheswcture is net intendedoroffemd formle(Sec.7044,Business
and Professions code:The Comractor's License Law does not apply to an owner of
property who builds or improves(hereon,and who does such work himself or through his
own employees,provided That such improvements arenot intendedorofferd6rsale.If, OCC.GROUP RES.UNITS
however,the building or improvement is sold within oneyear ofcompletion,theowner-
builder .will have the burden of proving that he did not build or improve for purpose of TOTAL:
sale.) ser s.If .
❑ Las owner ofthe property,on exclusively conlructmg with licensed connectors to QTY,g'r. ¢ri JPI'�UAIBING KRMIT" - 'I PEE v*f- FLOODZONE APN
concoct the pmjcn(Sec.7044,Business and Professions Code:)The Conan"..
License Lawdcesnotepplyte nownerofpmpenywhobuildsorimprovesther ,end PERMIT ISSUANCE
who contracts forsuch pmjmts with acommucions)licensed pursuant to the Contractor's
Licause[.uw. ALTER (EA)
FEE SUMMARY,
❑ I an,exempt under Sec. ,B&PC for This reason BACK FLOW PROTECT.DEVICE OUTSIDE FEE
SANITARY Y_N
Owner Data DRAINS-FLOORROOFARCAGONDRECEIPrN
, , , .
WORKMAN COMPENSATION DECLARATION SCROOLTA% Y N_
❑ I herebyaffinm that l have acertifemeofconsentte self-insure,ora senifcateof FIX'TURFS-PERTRAP RECEIPTp
Workers'Compensutien l nsumncearn candied copy docomf(Sec.3gW,Lab C.)WInch PARK FEE Y N
cove".11GAS-EA.SYSIN-1 INC.4 OUTLETS - RECE117k
Policyp
ref
DIVISION FLIS
Company ref 14}04�` L87 GAS-EA.SYSTF-M.OVER 4(EA) 1'IANCHECK FEE
s❑ Certified copy is hereby famished.
IyT Certified copy is fled with The city inspectiondivisinn. GREASEANDUSTRL WASTE I NTERCEPTOR GRADING ITT!
I CERTIFICATE OF FAEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This sectionneed oat becompletrd ifthe permit is(Drone hamdreddo11ms($10i SEWER-SANITARY-STORM IA.201 ENERGY HE
or IesxJ
I minify that in the perfonmunaof Ne work for which This permit is issued.I shot[ WATER HEATER W/VENT/ELECTR �
not employ my person in any manner so as to become subject to the Workers' _ PAID
Compmottionlswsof Cnlifomia Data WATER SYSTEM/IREATING Uma RaeiptM
Q z Afratemn
0 NOTICE TO APPLICANT.If,after making This Cenifcate of Exemption,you should NEW RESIDENT IAL PLMB. SQ.FT. �., TOTAL:
E y become subject o the Workers Compensation provisions ofthe Labor Code,you mum
forthwith comply with loch provisions.,,his perm,shall be,demand revoked. BUILDING HE
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
z Ihereby affum that hem is a construction lending agency for the performance of
U O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC I41i11
Lenders Name
0 0 U Landers Address Q j'{�`�' '�MECIIANICAL PERMIT 1, - FEE PLUMBING FSE
U I coolly that 1 have read this application and state Nat The above information is l;p'
correct. l agree to comply with all city and county onircuu s and state laws relating m PERMIT ISSUANCE � MECIIANICAL FEE
Vj hoildingronstmetiommrd hereby nmhurim represemmivesof this citymenturupon the CONSTRUCTION TAX
U 7 above-mentioned progeny for inspatian purposes. ALTER OR ADOTO MECH.
Ajudmts'
save,indemnify antl kap harmless the Ciry of Cupertino egeinn
Iiabiln expenses which may in any wayaccrueagaind mid City AIR HANDLING UNIT(TO 10,000 CFM)a.a. q n gef is permit.
AIR HANDLING UNIT(OVER 10,000 CPM)
Sign pplicum/Commcmr Date EXHAUST DOUG(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSUREHP.ATING UNIT(TO 100,(X%1 BTU) [)—.,aRecciplN
Will the applicam of future hinki ng occugmt stare a,handle hozarluus material I IIIATING UNIT(OVER IIN),I)IM BTU) TOTAL:
as dclincd by the Cupenino Municipal Code.Chapter 9.12,and the Beath and Surety
Code,Section 25532(v)7
El Yes ❑Na VENTILATION PAN(SINGLE RPSID)
Will TM1eepplicnmorfuturehuil(iing(xcupam useuryipmem unleviceswhich emit
BOILER-COMP(3HP OR 100,00)BTU) ISSUANCE:DATE
hazaalous air ceminumm is as defined by The Buy Arca Air Quality Management
DisWm7 BOILER-COMP(OVER I100.001)INPUT
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have read The hazardous muleriuls requirements under Chapter 6.95 of the OCT
Califomiu l lcalth&Sofety Code.Sections 25505,25513 and 25534. l understand that a
ifthe building does nm curten0y have a meant,thus iT is my responsibility to notify the l
oaupam of the requirements which must be mel poor to issuance of a Certificate of
Ocommoy. 11011 C/I y
Owneror authorized agent Dam A ISSUED BY: �II�O