26267 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 1111751NG-EL PI?RMI YNO.
BUILDING DIVISION BUILDING PROJECT IDEN
APPLICATION/PERMIT PLUMBING-MECHANICAL 26267
BUTIFICAI']ON
BUILDING ADDRESS: \^/ SANITARY NO. APPLICATION SUBMITTAL DATE?
L 019'—=S "k Tp LOTH —
\ OWN PHONE: COMfRACTOR'S NAME: LIC NO:
_
CON OLiI
CI :C / .1,1ER:ARF '
LIC NO: A ,.^ .- GI
CON]AM: PHONE: QATrYw } a' a " 't. "B n.
. ELECTRICrPERM1T!` IT +i + "BUILDING PERMIT INTO
£"' P' ¢ UA 5,•, s BDG 'I,I.ryCI' PLUMB C
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL IOB UFSCHILEB
I herebyaffirm that l am licensed under provism.sofehapler9(cammen<ing with
PTION
R-00-WUSection e Tai of Division J of the Business and Professions Code.end my license is in PANELS �ii
CW full farceandeffece ( �T P
6Fy License Class` Lic.p_m SC• _ _
m y pre Conuacmr CNk 201-1 A
F'� ARCHITECTS DECLAIL TION OVER 1000 AMPS' "" SQ.ff.FLOOR AREA S/SQ.FT.
O Z 4 q I understand my plans shall be used ea public records.
ass
(:.,y[ m SIGN CTR�fAL,�I n /�
Licensed Professional (�
OWNER-BUILDER DECLARA
TION PECIAL CIRC_U_R_/MISC.
Wi— I hereby affirmm that I aexempt from the Committers License Law Balm
o VV, following reason.(Section 7031.5,Business end Professions Code:Any city or county MP.METE
F of 5 which requires a permit ho comnum, he,,improve,demolish,or repair any terminate
�WT� prim to its issuance,also requires the applicant for such permit o file a signed statement POWER DEVICES "
ty C O p that he is licenaed pursuant the provisions of the Contractor's License law(Chapter
fi,En 9(commencing with Section71)(0)of Division J ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
W or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
ZaSection 7031.5 bymy applicant far a perrinumbjen,the epplicanno u civil penalty of
not more than rive hundred deltars(S5W). NEWRESIDENTIAL ELE SQ.FT. STORIES TYPE CONSTRUCTION
❑ I,usawnerof thepropeny,nrmyanploycexwith wngesus theirsolecnmpensetion,
a wb1do the work,and thestrucmro is nomlntendedmoffered forsale(5..4044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
property whobuildsorimprovesthercemand whodms such work himselforthmugh his OCC,GROUP RES.UNITS
own employ.,,provided that such improveenenm are not immidedor offered for sole.IL
however,the building orimprovemem is sold within one yearofmmpletion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
..':
❑suals.)1.uowneraDMprapeny,u exclasivelyc ntmaingwithli..dc.n.a,onm QTY?4I^�` PLUMBING PERMIT I FEE FLOOD ZONE APN
mnstmct the projcet(Sec.7044,Business end Professions Cade)The Conn ,.,'. PERMIT ISSUANCE
License Lew does not apply Rim o wncr o f property who bui Ids or i m proves thereon,and
who anomers forsuch projects with a contractor(s)licensed pursuanuo the Contimmes pL'TER-DRAIN&VENT-WATEA '
Li.nsc law. ER( ) - FEE SUMMARY
❑ 1 ani exempt under Sec. ,B&P C for this ration BACK MOW PROTECT.DEVICE. I' IDE FEES
SANITARY Y N
Owner Data DRAINS-FLOOR,ROOF.AREA,COND. saw RHCHIPTA
WORKMAN COMPENSATION DECLARATION SCHOOLTAX N
❑ Ihercby.sffirmthml have.cenificmeof consent to self-insure,or a milifmotn of 1?CFIPT
Worketa'Com FIXTURES-PER TRAP FEF N
pensatian Insurance ora cenifieJ copy thereof(Sec.3800 Lab CJ which PARK
erx ullempmyee's under this permit GAS-HA.SYSTEM-IINC.4 ETS HE TM
Policy II 1NG DI SIGN FEES
Company GAS-EA.SYSTEM-OVF 4(EA) PLANCHE
❑ Cenified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division. GREASFJINDUST ASTEINTERCEJpTOR GRADIN _E
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRA SOILS tH NJ
COMPENSATION INSURANCE
('This section need mals,completed ifthe Permit is for one hundred dollars($100) SEWER- ANITARY-S'I'ORMFA.200FT. ENER FF.R
or less)
I verify that in the Performance of the work for which this permit is issued,l shall WA HEATER W/VCNT/E,I,
not employ any person in.ray manner an as to become subject to the Worker' PAID
Compenatiun Lawsof California. Date KATER SYSTEMORJIATINGpace Receipt.
Q 2 Applicant
Z 0 NOTICE TO APPLICANT.If,after making this Certificate of Exemptim,ymimmild NEWRESIDENT'IALPLMB. SQ.FT. TOTAL:
Tq brmoidtomply it Workers Compensation Permit
eLibor Codgyou muv
? forthwith comply with such previsions or this permit shell be d.mcd mvokd. BUILDING FF.F, a/r
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that there is a construction lending agency for the Performance f TOTAL ELECTRIC FEH
U O the work for which this Perron is issued(S.301 Crv.C.)
Id, lenders Name k q d : : +
U F-t Lmnlers Address QATY,s T ri •sMLGI IANICAI PFRMI'1,d T y f 1 PE m PLUMBING FEE
U 1 certify that 1 have read this application and state that the above information
>1 Fk1 coram Iagr.to comply with all city and county ordmsMFCI3ANICAI.PERa<es and state laws relating to PERMIT ISSUANCE ��
F' building construction,and hereby authodu reprasentativesofthis city to enterupon the
U 2 miwe-mentioned property far inspection purposes. ALTER OR ADD TO NUCH. CONSTRUCTION TAX'
(We)agree to save.indemnify and kap he beleas the City of Cupertino against
liahilihiea,judgments.mats and expmeas which may iaanywaymemeagaimt and City AIR HANDLING UNIT(TO V0,000 CFM)
in umxqu race of the granting of Chia pe it. AIR HANDLING UNIT(OVER 10.000 CFM)
s-i8.9
Signat e A 1'an anwcmn Dme EXHAUST HOOD(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) 1 ��e Date Receipt N
Will the applicant or fame building ob,uptnt store or handle hazardous material
as defined by the Cupertino Municipal Coale,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU)
Code,Section 25532(a)P
El Yes C3 No VENTILATION FAN(SINGLE Ra-ID)
ISSUANCE DATE
Will thea licant orfmurcbuildin tease roue enwrdeviceswhich emit BOILER-COMP PITT OR 100,1100 BTU)
PP B pun quipm
haurdous air contaminants as defined by the Boy Area AG Quality Management BORER-COMP(OVF.R 100,(00 BTU)
AriatrinY p� .4 e
❑Yes ❑No NEW RESIDLNTIAL MECH. SQ.Fri. i"�
1 have read the hazmmus materials requirements under Chapter 6.95 of the J
Califomia Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that J7. ��
if tile pant o the res notcurrentlywhich
the a must
tar,[list rior myomancoibf a Ce i6eni the - 94
occupant but of the requirements note rre which east be mel Prior m issuance of it Cto rail c of �J[�
Owner or authorized agent Date L: ISSUEDBY: , A..
OFFICE