26935 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO TRI.I)ING-MECIIA PISRMrr No. (]
APPLICATION/PERMIT PLUMBING-MN.CIIANICAI. 9
BUILDING DIVISION BUILDING PROJECT'IDENI'IFICA'1'[ON
BUILDING ADDRESS: D L .n '� � SANITARY NO. APPLICATION SUBMITTAL DATE:
s UNIT# LOT
O PHONE: CONTRACfOR'SIJ�M, L NO:
rL, / N/C CONTROL p
ARCHTITCI'/ENGINEER: LIC NO: DRC S
sAfi/F ❑
CONTACT: PHONE: r 3 p.. T t'.•. ., ; _ . .
QT'Y, i:''s S ,Rr�FLECTRIC PPRMIT ° FCC "EUILDING PERMIT INFO
a BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ El El
LICENSED CONTRACTORS DECLARATION pppL1ANCE5-RESIDENTIALA TOB pF.SCRII'TION
p p.Z thereby affirm tbatlom licrnad undcrprovixions of Chepmr9(cormnencingwith
4100 Section 700E of Division 3ofthe Business and lhnlbasions Code,and my license is in PANELS
K WU full force and elle �.
F,Zed 4!T UP TO 200 AMPSc
,,o,y Due 201- 000 AMPS
)ONZ
(/1I
�
OVER IOW AMPS SQ.PT.Fl.00R ARE ISQ.FP.
O Z_q 1 undentand my plans shall be uxd m public records.
rc,'yW SIGNS ELECTRICAL
Q �,` Licensed l4ofewional
5tt OWNER-BUILDER DECLARATION SPECIAL CIRCUG7/MISC.
Ce. I hereby ul'limt that 1 nm exempt from the Co meter's License Lou,for the
p134-w following rtason(Section 7031.5.Business and Profusions Code:Any city or county TEMP.METER OR POLE INST.
which injoines a permit to construct,alter,improve,demolish,or repair any structure 100
W�f prior to its issuance,also regmres the applicant for such Permit o file a signed statement POWER DEVICES
W Ix p 0 tbut he is licensed puts.......he provisions a(the Contractors Liana low(Choptu
T
C4 9(unmmcncing with Section7000).fDlvlskm 3ofthe Businessund Professions Code) SWIMMING POOL ELECTRIC VALUATION
W—rn or that he exempt therefrom and the basis for me alleged exemption.Any violation of
[-. 6 Section 7031.5 by any applicant to,.permit subjects the applicant on e civil penalty of OUTLETS-SWITCHES-FI BS
^� mannuethan live landlord dollars(SSW).
Cp ElI,asownerofthepropcny,ormyemployeexwiN wagesaztheireolecompetw0on. NEW RESIDPNTfA ECTR _SQ. RIBS TVI'E CONSTRUCTION
W0 i It do the work,and the swemrc is not intended or offered for sale(Sec.7144,Business
anti Professions Crude:The Contractors License Law does not apply to an owner of VY
property whobuRdsorimprovestheecon.and wh.doessuchwork himxlfordtrough his OCC GROUP RFS.UNITS
con employees,provided thatsuch improvementsme not intended oroffercd forsile.If,
however,the buildingor improvcmem is sold within one year ofcnmplefion,the owner T
Within will have the burden of proving that he did not build or improve for purpox of
INasa❑ I,as owner of the progeny,am exclusively contracting with licensed contmctoa m QTY. r ."PLUMHINC I'IiR - �- PLOOD'/.ONE APN
construe the project(Sec.7044,Business and Profess ons Code)The Contractors
License Law does not apply men owner oPmearty who hui Ids or improves Position,and PERMIT ISSUANCE
whoinstrument for such projects with a contractors)liasxd putsuanuo the Contractors ALTER-DRAIN&VENT-WATER FA FEE SUMMARY
License,Low. ( ) -
❑n1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE SID,FF.,
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT'#
• � n WORKMAN COMPENSATIONDECLARATION SCHOOLTAX Y_N
1�/I hertbY alum that l have a certificate ofecosenno self-insure,or a certificate of RECEIPTp
Worker Compensation Insurance oracertified copy thernd(Sec.3800,Lab CJ FIXTURES-PER TRAP which PARK FIiC YN
covers ell c�o�-un 1 h s permS�s - RECEI"#
Y//U GAS-IrA.SYSTEM-I INC.4 OUTLPTS
Policy p- BUILDING DIVISION FEES
Comfort
- GAS-EA.SYSTEM-OVER 4(fA) PIANCHECK PER
❑_Certified copy is hereby famished.
Certified copy is tied with the city inspection division. GREASEANDUSTRI.WASTE INTERCEPTOR GRADING PEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completM if Ne permit is forone hundred dollars($HXE SEWER-SANITARY-STORM EA.201 ENERGY IME
or less.)
I certify that in the performance nflhe work far which thispcnnit is lacteal,I shall WATER HEATER W/VENT/HLEC'I'R
not employ any ponos in any manner sat as to became subject to Ne Workers' PAID
z in
Commution.L....f Cnlifomia. Date WATERSYSI'RMaREATING Dom Receipt It
Applicant
z00 NOTICE TO APPLICANT,If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
V) become suhjem to the Workers Compensation provisions ofthe lobar Code,you..at
� , ftmhwifh comply with such provisions or this permit adult be domed revoked. BUILDING FEE
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
Uz Ihereby affirm Nalthen is a construction Tending agency for the performance of TOTAL: ELECTRIC FEE
O the work for which this permit is issued(Sec.3097,Civ.CJ
,r Isnders Name FEE
0 U Isndcr's Address QTY, MECHANICAL PERMIT PEE PLUMBING
1 certify list I have read this application and stem that But above i ..tion is
comi l agree to Comply withall city and/mm w rejoingm FE
PERMITISSUANCE MECHANICAL E
building conswmion,and herehyu mreprtxnmtiveno is Cry, a ter upon the
U z aMve-mentioned property for i e onpurpnxs. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We nal and kap acro ens Ne Ci o rtin.itl
Iiuhilit 'uA mem otos nt nseswhich .anyway cc a� ity AIR HANDLING UNIT(TO 10,000 CFM)
e Ihispermil.
AIR HANDLING UNIT(OVER 10l.CRE
aI.M.LAER15I.A0 Our ate EXHAUSTHOOD(W/)UM)
PAID
HA RDOUS MA'I ERIAIS DISCLOSURE HFATING UNIT(TO 1000)0 BTU) Date Receipt#
Will the applicanttar future building..,.t store or handle hvardous material
as defined by the Caper,inn Municipal Code,Chapter 9.12,and the l health and Safety BEATING UNIT(OVER 100,000 BT'll) AL
Code,Section 25532(a)Y
1-1 Yes ❑No VENTILATION FAN(SINGLE RPSID)
BOILER-COMP(31111 OR 100,Ott)BTU) ISSUANCE DAT
Will tair ,contaminants
ax building by thenmx Area Air .alit Management P. q
hamrdous air contaminants as defined by the Boy Area Air Quality Management BOILER-COMP(OVER IOEM BTU) s4
Diamea
❑Yes ❑No NEW RESIDENTIAL MECIf. SQ.FT.
I have read the hazardous materials requirements under Chapter 6.95 of the UG 2f 519gq
California Health&Safety Cods,Sections 25505,25533 and 25534.I understand that Vr
if the hui lding does not currently have u tenant,that it is my respureibi li y m notify toe
occupant of the requirements which must he mes prior to issuance of a Certificate of �urrMt
Occupancy.
Owner or outhnrizcd agent Dam TOTAL: ISSUED BY:
OFFICE