26793 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
PERMIT N0,
CI'PY OF CUPERTINO PLUMBING-,.,,.,MECHANICAL CAL ^
BUILDING DIVISION APPLICATION/PERMIT2679 4
BUILDING PROJEC I'IDENTIVICA UPON
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMHTALDAT
UNIT# LOT# 7�7st
E:
WNERSNA PHONE: CONTRACTOR'S NAME: LIC NO:
^
C N/C CON TKOLL#
AR 1 TECf/E.GINEEIC LIC NO: DESS: _ ❑
IA
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ISI El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TIL
Ozz Iheacbyaffirnthatlamlicensed unOerprovisions of Chapmr9(commenting with 100 DESCRIPTION
WOO Swim 7000)of Division 3 of the Bminess and Professions Cade.and my license is in PANELS�W_ fall force and effort.
/
FZm License Clazs Lic.# UP T0200 AMPS
m=y Dane Convacmr 201-1000 AMPS
F'tnZ ARCHITECTS DECLARATION OVER 1HppAMPg r SQ.FT.FLUOR AREA $/SQ.FT.
ZO � I unJerstunJ my plan..shall bo used us public records. TY p /5 fl ss.
�7n5t SIGNS ELECTRICAL I \V'I /^\ Ill 1, D Hill
E,, Licen.,ed Professional
a�t+�1U OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. ��J� n p p
KO W U 1 hereby frim,that 1 am eser,t from the Contractor's License Lew for the L--l/�/�'�s� II
W'3 a y following reawn.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST. l
O Q which acquires a permit m construct,alter,improve,demolish,or repair any sometime
fuVu1'1>� prior to its issuance,alsorequires the applicant for such permit to file sopel statement POWER DEVICES DAIS 7 �� CI
�Oz that he is licensed pursuant m the provisions of the Com License LicenLaw(Chapter SWIMMING POOL ELECTRIC
aao 9(commencing with Section 7")of Division 3ofrhe Business and Professions Code) VALUATION
y _y onhan he is cwhapuherefromand the buxom mathe alle,odesemption.Anyviolationaf OIITLEI'S-SWITCHES-FIXTURES
Fla Section 9031.5 by any applicant for a Permit subjects the applicantto a civil penalty of
T O
Out..or than five hundred dollars(4500).ropeNEW RESIDENTIAL ELECIR _SQ.FT.
z CFS ❑ Lasownerafthepny,ormy empinyecswith wages astheirsolecompemation, STORIES TYPE CONSTRUCTIOI
y5_ will do the work,and the structure is not intended or offered new mic(Sec.VD40,Business
and Profcssiom Code:The Contrzc m's License Law does not apply to an owner of
property who builds or improves thereon,add who does such work hurselfor through his
own employees,provided that such improvements are not intundedoroffired forsale.If, OCC.GROUP RFS.UNITS
however,the buildingor improvement is sold withinone yearofcompledon,the owner- TOTAL'
builder wlll have the burden of proving that he did not build or impmve for purpose of
.ale.).
CI Las owner of0le propenY,am exclusively contracting with licensed contractors m QTY. PLUMBING PERMIT FEE ---FLOOD ZONE. APN
coneswct the project(Sec.7010,Basin.and Professions Code:)The Comnchrs PERMIT ISSUANCE
License Law doesnmt apply hurt ownerofproperty who builds or improac
vestheon,and
whocent=a forsuchpmjwc withaconu togs)Bcens pumuamtoihe Contracmfs
Licrmc Law. ALTER (EA) FEE SUMMARY
❑ 1 am cxcmpt under Sec. B&P C for this mazon BACK PLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN
Owner Date-
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y
lhcmby afDRAINS-FLOOR,ROOF,AREA,COND. RECEIYI'#
1 N
❑ firm that ocedi0cate of consenuo ure
hf-insu ,or of RECEIFT#
�
FIXTURES-PER TRAP
WorkersCompensation�W�rumnce orucenifiedcopy therrogS«.3800,Lab C.)which PARK FEE Y N
co
crs al
ulic� , ry71"i.yTp#it-,� GAS-EA.SYSTEI INC.4 OUTLETS RECEIPT#
Yc'7 lJI,L��r q BUILDING DIVISION FEES
�lA/I1 r M-GAS-HA.SYSMlvfOVER 4(EA) PLANCHECK FEE
H Certified copy is hereby frmishW.
❑ Certified copy is flet will:me city inspection division. GREASEffNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This climinaddot be«smpleted ifthe permit is forma,hundred dollars($100) SEWER-SANITARY-STORM EA.200Ff. ENERGY FEE
or less.) ']
Icenify that in the cerformanee arms work for which this perm it is Owed.I shall WATER HFBTER W/VENTIELECIR w
not employ anY Perron in anY manner w az to become subject to the Wolters' PAID
O ,z Compensation Laws of California. Date 1 WATER SYSTULREATING Date Receipt It
Applicant -
z0 NOT ICE TO APPLICANT.If,after making this Certificate of Exemption.you should NEW RESIDENTIAL PLMB, SQ.FT, TOTAL:
F' fn become subject to the Workers Compensation provisions of the Lidur Code,you must
7 forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
6W. CONSTRUCDIONLFADINGAGENCY I SEISMIC FEE
Vz 1 hereby affirm that there is o construction lending agency for be Performance of
O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ,Qp ELECTRIC FEE
lenders Name
OF Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE s p
U I certify Nut 1 have read this application and stu¢than the above information is
c Tree,.I agree to comply with all city and county ordinances and sante laws relating to PERMIT ISSUANCE MECHANICAL FEE
F' buildingc—Oration,and hereby emhoriu representutives of this city heater upomhe
V z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)egret In save,indemnity and keep harmless the Ciry mf Cupertino agahut
liabilities.judgrmans,coo¢andeapmea,which may inanyway unarm against said Ciry AIR HANDLING UNIT ITO 10,000 CFM) fs
race ue, ftheg nfn oft is permit.
AIR HANDLING UNIT(OVER H0,000CRA)
Signature of AppllcanUCon rnr Dam EXHAUST HOOD(W/DUCT) al
PAID al
HAZARDOUS MATERI DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dat, Receipt#
Will the applicant lir future building Occupant store or handle hazardous material HGTING UNIT(OVER 100,0W BTU) TOTAL: (j sop
as defineCupertino Municipal by the CupertiMunicipal Code.Chapter 9.12,and the Health and Safety
Crale.Seen 25532(al'1
11 Yes 0N VENTILATION FAN(SINGLE RPSID)
BOILER-COMP OHP OR 103,000 BTV) ISSUANCE DATE
Will theaconta contaminants
dullard by be Bay A ipmir orality whichemitPAID A i D
hazardous air comaminunts az defined by the Bay A.Air Qm1iry Manugenmm g01LER-COMP(OVF,R 100,(00 BTU) O!
District?
❑Yea ❑No NEW RESIDENTIAL MECH. SQ.IT.
I` I have read the hazardous materials requbcmems under Chapter 6.95 of the JUL 27 1994
Culianala I health&Safmy Code.Sections 25505,25533 and 25534. 1 underemad that
if the building drcs not currently have a tcnam.that it is my responsibility to notify the �(}pIY Ur wren ulvU
occupant of the requirements which must he,met prior to issuance of a Certificate of
Occupancy.
Owner or authoruA agent Date TOTAL: ISSUED BY: