26769 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ..IL"INC-BUNG TR PERMITNO.
APPLICATION/PERMIT PING PRoG.(:r ID NIWICL 26769_
BUIL131NCr DIVISION RUILDLUMBING-MECHANIFICA'I']ON
UAL
DING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT
c o!
UNIT1. 1'0
": rLICNO:WNEPH IFALSVVVne
T N/C COMBOLB
RCIII'1'F,CDMUINEER: LIC NO: ADDRESS: ❑
e1NTper: PHONE: QTYe�'. gPLEC[1L.IRIC PERMIT x' FEE ''�e.BUILDINGPERMIT INFO' - .
F. F,CT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRAerpraSDECLARATION pppLIANCRS-RESIDENTIAL JOB DESCRI Ipy-
pyz IherehyxlEnn that lomlicenscd underprovisionenl Crapmr9(commencingwiN `/,J1`py-rkY^��oif�ClV�rs {,et,
+1100 Section 780)of Division 3 at Easiness and professions Code,and my license is in PANELS
,ybrE fail force and effect.
F L,W License Class Lic.4 UPT0200AMPS
F?y Dam Contractor 201-1000 AMPS
ZOyS ARCHITECTS DECLARATIONOVER 1000 AMPS l- I, rA5 �pISQ. 4. RAREA 5/SQ.FT,
p z., 1 undemm�J my plans shall be used as public recoMs. \
�7m ® SIGNS ELECTRICAL 1 ..✓✓
Licensed Pmfcsaianel ��
OWNER-Bempt from
the C ummoN SPECIAL CIRCUIT/MISC. `- jjj I� I
S5d�OaF 1 hereby affirm that 1 am exempt from the Cosion,Co License Law for the0�
I+13 ran following rcusnn.(Sailor 7011.3.Business and Profasiom Cade:Any city or cowry TEMP.METER OR POLE FIST. DA I -
F-�0.] which requires a permit m construct,alter,improve,demolish,cr repair any structum D
Y5 prior to its issuance,also requires the applicant forsuch permit to file a signelmotiment POWER DEVICES
W ap that he is licensed pursuant to provisions of the Comraaors License Low(Chapter
9(commencing with Section 7000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
WM, or that he is exempt herefrom and the basis for the alleged exemption.Any violation of Eb OUTLETS-SWITCHES-FIXTURP.S O
1_7Y Section 7031.5 by any applicant for a permit subjects the applicant macivil penelry Of
Q r e than five hundred dollars($500).
I,asowneroDhepropeny,nrmycmployeeswithwages astheirwlecompensetion, NEW RESIDENTIAL ELELTR _SQ.Ef. STORIES TYPE CONSTRUCTION
wi dollmwork,andthestmckne ie not imm�dedoroffcrcd fm sale(Sec.]M4,Business
and romesiens Cada:Lie Comra rm`' License[.am does not apply to an owner of
I, who builds orimproves thereon,and who dote such worklJmselfunhrough his
wn emp oyees,providedthat suchimprovements srenot intendeJoroffered Torsade.If, OCC GROUP RES.UNITS
however,the building or improvement is sold within one year of completion.the owner- /
builder will have the burden of proving that he did not build or improve for purpose of
s❑)I,as owner ofthe property,am exclusively contracting with licensed conttactont QTY, k :PLUMBING PERMIT " FEET FLOOD ZONE APN
construct the project(Sec 7044,Business and Professions Coda:)Tho Contacmrs
License Law doesnorapply loan Uwnerofpropcny whobuildsorimproveadmocom and PERMITISSUANCE
who contacts forsuch Amies with acommuctor(s)licensed pursuentto the Contractors ALTER G
License Law, f' ) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE SANITARY YID ID I1 N
Owner DoleRAT DRAINS-FLOOR,ROOF,AREA,GOND. RECEIPTg
WORKMAN COMPENSATION DECLARATION DRAINS TAX Y N
❑ Iherchy nffirm lhetlhaveecenificam of consent to self-insure,orncenilicom of FIXTURES-PER TRAP RECEIPT4
orkers'Compmeation Insurance or o certified erm00
copy thf(Sec.38 ,Lab C.)which PARK LFL Y_N
en ell employa's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT 11
Policy g BUILDING DIVISIObLEEU
Company GAS-EA.SYSTEM-OVER 4(EA) P L A N C I II,CK MI,
[I Cenifed copy is hereby famished.
❑ Candied copy is Eled with the city inspection division GREASEANDUSTRL WASTE INTERCEPfOR GRADING PER
CHRTIFlCATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS IEE
COMPENSATION INSURANCE
(This saomrithednot b,completed ifthe permit is toren,hundred dollars($100) SEWER-SANITARY-STORM FA.200FT. ENERGY FEE
or Tess.)
I certify that in the performance of the work for which this permit is issued,T shall WATER HEA'1'ER W/VCNT/ELECIR
not employ any person in any manner so as to become subject to the Workers' PAID
Compensation Luwsof CaBfomia. Data WATER SYS9EMTIMATING Date Receipt It
O Z Applicant
Z LD NOTICE TO APPLICANT.If.after making this Cenifcate of Exemption,you should NEW RESIDENTIAL TIME. SQ.FT. TOTAL:
rti became subject to the Workers Compensation Provisions of the Labor Code,you must
a ; forthwith comply with such previsions or this permit shall be domed revoked. BUILDING FEE
F z CONSTRUCTION LENDING AGENCY SEISMIC FEE d
I hereby affirm that there is a consuudion lending agency for the perfrmaance of
VQ the work for which this permit is issued(Sa.3097,Civ.C.) TOTAL: ELECTRIC FEE
Isnders Name PLUMBING FEE
IT.
U Lenders Address QTY. -- MECI IANICAL PERMIT FEE
1 candythat L have read this application end stem that the above information is t;I. I A
7" 4 correct.la gree ua cont I with all cit and count g MIiCIIANICAL TEF.
S comply y county end start laws rclmin m PERMIT
building construction,and hereby authorize reprcsenmtivesofthis city to enter upon the CON59RUCTION TAX
C-) 7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and kap harmless rhe City of Cupertino ageir,xt
liabilitim,judgmenb,costs and expenses which may in any wayaocrueagai sold AIR HANDLING ONG CFO R).000 CFM)
intc the g petmjln
AIR HANDLING UNIT(OVER 10,000 CFM)
Statute�' cant/ seer lam EXHAUST 11001)(W/DUCT)
PAID
HAZARDOUS MATERIALS 'CLOSURE HEATING UNIT(IO I0RDg BTU) Date Recciptp
WRIffie applicant or future building occupant smrc or handle hamorkas mneriaT IIFA'I'ING UNIT(OVER 100,(gl)BTU) T
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Cade.Section 25532op?
Yet,
❑Ycs El Na VENTILATION PAN(SING LF.RESID)
Will theapplicanmrfmurc buildingacupant useequipmem ordeviceswhich emit
BOILER-COME 3HP OR 100,000 BI'U) ISSUANC ATE
hazardous nit commutators es defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100,o0o RTU)
Distrix:
13EIggi�pp p ]
Yes No NEW RESIDENTIAL.MECIL SQ.FT. P .4 I p,
1 have read the hazardous materials requircmmrts under Chapter 6.95 of the 4/
California Health&Safety Code.Sections 25505,25533 and 25534.1 understand Nat UL 1 g
if the building does not currently have a Imam,that it is my responsibility to notify the
ocolitic,of the requirements which must No at prior to issuance of a Cenificom of
ccupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:~ ' / _V