26199 APBLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOtm:n/Nrr.bI.b17uica. PFUMfr NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. ,26199
BUIL131NQ DIVISION BUILDING PROJECT'IDENTIFICA'I[ON
BUILDING ADDRESS: Q ��l'�/�'�� SANITARY NO, APPLICATIIOON�SUUBBMITIA(LE.
�DAT
'rTS 1P •-c r el/1/✓J ^"tea ITN LOT#
OWNERS NAME: PHON��C � CONTRAC'TOR'S NAME: LIC NO:
CONTROLk
�
AACNFFIMBBR: LIC NO: ADDRESS: ❑
CONTACT: PHONE: -
QT`Y, ,R� yy EEECTRICPERMIT. FEES • - - }HUICDING PERMIT INFO
"l'V"" °' BLDG ELECT PLUMB MECII
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
fizz Increbyaffirmtnat lam licenum underprovisionsurChapmr9(commencingwim JOB DESCRIPTION
tD00 Section 7000).f Division 3 ofthe Business and Professions Code,and my li¢rtae is in PANELS
FKUE fullfarceandeffect. i j (3J � l�IZA6lAl
<Z, License Class Lic.N UP TO 2W AMPS e�
r <o.Di, Date Contractor 201-I"AMPS
zOyZ� —ARCHITECTS OVER IOWAhIPS SQ.PT.FLOOR AREA S/SQ.PT.
0 Z O I underatand my plana shat[be used as public racoma.
I:,oe t:iqSIGNS ELECTRICAL
Y Licensed Professional
XO < OWNER-BUILDER DECLARATION SPECIAL CIRCULDMISC.
aU I hereby affirm mm 1 am exempt from the Contractors License Law for the
w 3 Woo following reason.(Section 7031.5,Business and Professions Cde:Any city or county TEMP.METER OR POLE INST,
C IS which requires a permit to construct,alter,improve,demolish,or repair any structure
i� prior to am issuance,also requires the applicant for such permit o file a signed moment POWER DEVICES
ty GO that he is licensed pursuant to the provisions of the Convector's License Law(Chapter
P. 9(commencin with Section 7000)of Division 3 of the Business and Professions Code SWIMMING POOL ELECTRIC
o� (commencing ) VALU 'I1'OpNJ,,
µ�j❑m or that he is exempt therefrom and me basis for the alleged exemption.Any violelion ofy
F. a Section 70315 Permit by any applicant for a Peit subjects the applicant to a civil penalty of OUTLETS-SWITCHES-Pf%TURES
^� G not more than five hundred dollars($500).
K pr pry,ormycmployeeswimwagessstheirsolecompemalion, NEW RESIDENTIAL ELECIR 5 .
❑ I.mownerofthe o Q SI'ORIFS TYPE CONSTRUCTION
y3— will do the work,enAthmwdua is not intendedaroffercdforsalc(Sec.]IH4,Busineaa
and Professions Cale:The Contractor's License Law does not apply to an owner of 1
pmperywyces,pdsorimprovesthemprove wn.menot ended rofferedmroughhis ice„ t t OCC GROUP RES.UNITS
empioyeeailding rti thatovenimproauld,tin ne year
theaforsanIf,
buwevepillhathe v l the burden(if
improvement thinonebuild of cnmolefor purpose of n — TOT-Al,
huilAer will have the Horden of proving that he Aid not build or improve for purpose of '^ 1 / n �"
o ) d P
s Ie Las ownerofthe ro nexclusivelyQTYz a PLUMBING PERMIT FEEm' n.00D ZONE APN
❑ p . Y,4, and contracting CWe:)The ontnuous ,.A- (
romwd the project(Sec.]844,Business and Professions Cale:)The Continuous PE MIT ISSUANCE /
License Law does not applyto an owner of proper y who builds a improves Contrathencon,and
who acts for such projects coir aconvxtorta)licrnsd Location to Contractor's r'�LL
License Law. � ALTER I.� - ATF.R(EAS FEE SUMMARY
❑ I am exempt under Sec. ,B&PC for this reason BACKPLO W PROTECT.DEVICE. SANI'T'ARY TY N
Owner Date pµglNS-ILOOR,ROOP,AHIiA,COND. RECEIPT.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Thereby affirm shell have ecerificom of Consent to self-insure,orecenificam of
FIXTURES-PER TRAP RECEIPTN
Wakers'Compensation lnsoraneeoracerifidcnpy thereof(Sec.JgM,Lab C.)which PARK FEE Y—N—
covers all employee's under this permit. GAS-FA.SYSTEM-1 INCA OUTLETS RECT:I"#
Policy g BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER4 HA) PLANCHECK FEE
[I Carolled Carolled copy is hereby famished.
❑ Carolled copy is filed with the city inspection division. GREASIONDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF E%EMPTION FROM WORKERS GREASE TRAP SOILS IEE
COMPENSATION INSURANCE _
(This section red not d completed ifthe permit is for one hundred dollars(SIM) SEWER-SANITARYCS'M" _ '�1 ��;� ENERGY ITE
or lcs
I certify that in the performance of the workfor which this permit is issued,l shall WATER LIEF,7,
not employ any person in any mummer
eco as to become subject to the Workers' y/ ""- PAID
z Cm%arsatm Laws.f Celifmd.. Data WA'I'ERSI j�v`;j.,wm WG Data Rceciptg
Applicant
z 0 NOTICE.TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
pV) become subject o the Workers Compensation provisions of the labor Code,you must
� > forthwith comply wim such provisime,.,,his permit shall be deemed revoked. BUILDING FEE C. 00
1 CONSTRUCTION LENDING AGENCY SEISMIC FEE f
Vz 1 hereby affirm that hem is a concoction lending agency for the peffomunce of 1
O the work for which this permit is issued(See 3097,Civ.C.) TOTAL: ELECTRIC FEE
Lender a Name
red mPLUMBING IEE
W
0 I<ndaYs Address QTY Ir,h MPaCAANICAL PHRMITp - EHE,
U I century that 1 have this application.nil m that me above information is 6
carred.lagree menmply with ell city and runty ominanr<e and stnelows relating to a PERMIT ISSUANCE MECHANICAL FEE
F-' U-) building construction,and herebyaumonze representatives affiliate city to enter upon the
U Z above mentioned Property for inspection pmpn_ ALTERORADDTOMECIL CONSTRUCTION TAX
We)agree to save,indemnify and keep homeless the City of Cupertino aga emu
liabilities,judgmems,co I and noses which may monywayaccrveagainstsald Ciry AIR HANDLING UNIT(TO IIk000CFM)
in cnnsequrncyeR((���i�a�l//me gamins I.
2 AIR HANDLING UNIT(OVER IO,flfgl CFM)
Signamre.f Applicam/Contactor G-bute 1:%IIAUST HOOD(W/DUCE) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.010 RTU) Date ReeeiPtp
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100.000[)TO) TOTAL: � r
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(x)1
12 Yes 1:1 No VENTILATION FAN(SINGLE RESID)
BOILER-COMP LIHP OR 100.000 BTU) ISSUANCE DATE
Will the applicant
emim iname arc defined by the
nBay AuipmirrtQualit cManaes gement P A D
h,,mc,? air c.nleminams as defined by the Bay Area Air Quality Management BOILER-COMP(OVER IW,0110 BTU)
�DlsviCl? .
❑Yea ❑No NEW RESIDENTIAL MECH.—SQ,IT.
I have Rad the hazardous materials requirements under Chapter 6.95 of the MAR 2 51994
Calif tram Health&SafetyCode,Sections 25505,25533 and 25534. I undeatand that
if the building dne.wot tomcod arcnnnt.thm it is my responsty to nmifyme CI I UI lz Ul'L'T1111VU
cupunt of me r t.i,v e o
Ownermianhanzd agents at TOTAL: ISSUEDBY:41
OFFICE