26089 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY Q
CITY OF CUPERTINO PLUMBING-MECHANICAL, PFJEMIT NO. 26089 O H V
BUILDING DIVISION APPLICATION/PERMIT G
IIUILUING PROJECT'IUENTIFICKFION
BUILDING ADDRESS: SANITARY NO. APPLICaAT�IONSUUBBMII/TTALLDATE
Y/•
UNIT LOTp Ifs
OW S E: GNB: CO CI'OR'S NAME LIC NO
O
\w� D I/ � ' N,C CONTkOL N
ARCUITECT/F INEER: LIC NO: ADDRESS: s V -d L`Z ❑
I S®C�Mme/ 6 S
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT PEE
BLDGCf PLUMB MECH
PERMIT ISSUANCE [:] ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
❑f�Z, Iherebyaffimt Hntlam licensed undcrprovieions ofChepter9(commencing with 1 D S r�
POO Section 900o)of Division 3 ofthe Business and Professions Code,and mylicerrseisim PAN.pLg I
y U full force and effect.
'Z W License Class Lic.af IIP 70200 AMPS
rFii?h Data Com[raom, 201-1000 AMPS
Z O m Z, ARCHITECT'S DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA VSQ.IT.
O Z—O I understand my plans shall be used as public records.
y
SIGNS ELECTRICAL
t Qy, j L¢ensal Professronel
(Yyd'4 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
He,O e,F 1 herehy affirm Hm I am exempt from fi
e Contractors License Law for the
W 3 rn following reason.(Section 703 LA Business and Professions Code:Any city or county TEMP.METER OR POLE MST.
which requires a permit to commuct,idea improve,demolish,m repair any srveturo
hya� prionoits issmance,ako requires the epplican[forauch Perrino file asigned statement PDWER DEVICES
W OO that he is licensed pursuant o the provisions of the Contracmrs License Law(Chaptert
d�o�' 9(commenciagwith Section 7000)of Division 3 ofthe Businessand Professions Code) SWIMMING POOL ELECTRIC r� _ , [=i VA U TO
w 2co Or that he is exempttherefrom and the basis for the alleged exemption.An ,a -"
g P Any of OUTLETS
a
Section than by any hundred dollars
subjects the applicanuoecivil penalty of SWITCHES-FIXTURES I u
not more than five hundred dollars(5500). nGR 22 Cl I,the wrk,of Hepropeny,orm toed orroferefarstheirsce.cum NEW RESIDENTIAL ELECT# _SQ.'FT.
yemp y g pensation, % � NSTRUCDON
°.° willdothewons ande he Coreismor's License Law does fapply to ren Business
and Professions Code:The ves t covin,License Lew does not apply lf an owner of nATE
ispropertywhees,Idsartimproveu Heron,and whsme nsuch work reoff rodthroughhisown employees,lding a ual improvemch ent mcold withittme ear.edoroffered forsale.lf, S.UNITS
however,the building urdenmpment ie sold withinomeyemw improlve for theownerTOTAL:
h le.). will have the burden ofproving that he did not huild or improve for puryose ofsale.).❑ I,asowneroftheproperty,amexclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEE APN
convtruel the pmject(Sec.7044,Business and Professions Code:)no Contractor's
License Lowdoes not apply m an ownerofpropeny who builds or improvestharaon,and PERMIT ISSUANCE
who eommm,far such projects with a contriamE)licensed pursuant to the Conveomr's
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE MES
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX y
` ❑ ens'Co afthmth Insurance macerteof consent to self iec.380ra IE C.)ewhich FI%TURES-PER TRAP RECEIPT#
Workezi Compensationder this cmaicenifiedcopy thereof(Sec.3g00,lab CJwhich PARKFEE Y N
covers all employee's under this permit.P//' (�S GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy# ; s"�1 '�_ BUILDING DIVISIONFF.
y T—� GAS-EA.SYSTEM-OVER4(EA) PLANCHECK FEE
rtif1eACopy is M1ereby famished. 1
Certified copy is filed with the city inspection division GREASE/INDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need rumbe completed ifthe Permit is for one hundred dollars(g1)0) SEWER-SANITARY-STORM EA.201FT. ENERGY FEE
or leas.)
I certify that in the performance of the work for which this permit is issued,I shall WATER HEATER W/VENT/F.LECTR
not employ any person in any manner so as m become subject to He Workers PAID
Compensmmu laws of Ca1lPomra. Date WATER SYSTFAITREATING Date ecegh 0
0 7-+ Applicant
z 0 NOTICE TO APPLICANT:If,atter making this Certificate of Exemption,you should NEW RESIDENTIAL PLMR. SQ.FT. TOTAL:
r � become subject to the Workers Compensation provisions of the Labor Cade,you most
moi , forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
pW, z
CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the performance of
IJ O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE d
L. ,r Lender's Name
O U Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
W I certify t eve d this application and state that above inf rmadon is MECHANICAL. E
a erect.la c plywr all city and county oninances and scale laws relating to PERMIT ISSUANCE.
bidding. s ci n dher youth.' represenmtives ofthis city to enterupantto CONSTRUCTI NTA%
U 7 above- of y for naNction urposes. ALTER OR ADD TO MECH.
rte— ( aga ,'ad mnify keep harmless the City of Cupertino against
liabilit JudJudy, n ostms which may inanyway accrue against said City AIR HANDLING UNIT(TO IQ000 CPM)
in s¢
conaft grant thly permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Toro
rg arure of ppli t Date EXHAUST HOOD(W/DUC)
PAID
HAZA MATERIALS DISCLOSURE HEATING UNIT TO 100.000 BTU) Date Receiptq
W ill the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL;
Code,Section 25532(a)4
❑Yes 0 N VENTILATION FAN(SINGLE RESID)
BOILER-COMP UHP OR 100,000 BTU ISSUANCE DATE
Will Heupplio tmrfumre buildfngoccupantuseaqulpme tnrdsvio swhich emit )
Ita'nor.s air contaminants as defined by the Bey Area Air Quality Management BOILER-COME(OVER 100,000BTU)
Diatrim't
❑Yes 13 NO NEW RESIDENTIAL MECH. SQ.FT. P A D
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand ohm -
if the building docs not curently have a tenant,Hat it is my responsibility to notify the WAR - 3199
occupant of the requirements which must be met prior to issuance of a Certificate of
Oreopeary.
CL. .
Owner or authonud agent Date TOTAL: ISSUED BY:
OFFICE