26070 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPL'RTINOBUILIJJ G-ELM;IHICAL - TERM['[NO. I/•�� 7
APPLICATION/PERMIT PLUMBING-MECHANICAL 260 1 O
OUILDING DIVISION - BDI
UILNGPROJECI'IDiIN'1'IFICATION
BUILDING ADDRESS' /'��� INITp Sc� 12-^ •/ SANITARY NO. APPLICATION SUBMITTAL DATE
O I Fes. i\� _PHONE' I RACfOR'g NAME' LIC NO:
'
N/C COMIR
®ARC TiCf/IiNGJNEF LIC Off. A�WIESS: ❑
CON CI': C!J PHONE. BUILDING PERMIT INFO
%D� /��� QTY. ELECTRIC PERMIT FEE
M Ii1.DG EI .CT PLUMB MUCH
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDF,N9gAL 'I BDESCR ION
M%z I hereby affirm that l am licensed underprovisioneofChapler9(commencing with
POO Section 7001 Division Sof Be Business and Professions Code,and my license is in PANELS
W full force and effect.
V UP TO 20)AMPS
6Z Dae' Class Contractor
vFiQZ Dare Gonmmor 201-11g0 AMPS
Of° SQ.IT.F OR AREA S/SQ:Ff.
ZZ—O t,0mll hicu,e'ECTSDI?CLARATION OVER IWO AMPS
O Z�O I undcrxl:md nsy plans steel I he used as public records.
fC.tttyyy Q SIGNS ELECTRICAL 2 Licensed Professional
L' 6'
60x0 BDECLARATION SPI7C1AL CIRCUIT/MISC.
hereby affirm that I am exempt from the Commcutrs
License Law for the
u�34co following immar.(Section 703 1.5,B usinew and Profeattow Code:Any city or county TEMP.METER OR POLE INST.
C.I']us which requires a permit to construct,aheq improve,demolish,w repair tray stncroom t
M� prior to its isxuancq also requires the applicam for such pertniuo fit align enumeration POWER DEVICES
,ZR�nos that he is licensed pursuant to the provisions ofthe Contractor's License Law(Chapter
o•0.pEd 9(commencing with Section 7000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC A ATION
Xyl_y or that he is exempt therefrom and the basis forlhealleged exemption.Any violation of
i• Swtion 70315h applicant t subjects the applicanuoacivil OUTLETS-SWTTCHIS-PIXTURGS
5Z< Yive hundre icon permi su 'e penalty of
W�mnot morcthan rofhepro ril,ormyem). NEW.RESIDENTIAL ELECTR —SQ.FT.
❑ I,osowneraftheproperty,ormyemployeexwilh wagesmNcimnlecompcnvutien, STORIES q'YPL'CONS'I'RUCI'ION
a will Jo the wnrk.and thestruumrc is not dowdedwaffcied boards(Sec. Business
and professions Coe:The Commcmr'a Litems,Law does not apply to an owner of
property who builds or i mpmves thereon,and who does such work himselfor through Itis
own employees,Provided Nal such improvements are nm intended or offered for sole.IL OCC.GROUP RES.UNI"TS
however.the buildingor improvement is sold within one yearofcompletion,the owner-
buildef will have the burden of proving that he did not build or improve for propose of
sale.).
❑
has owner oflhe property,am exclusively contracting with licensed contractors to QTY' PLUMPING PERMIT ITE FLOOD ZONE APN
on.nmm the project(Sec.7114,Business and Professions Coder.The Contractor's - -
LicenseLawdoexamapplytoanownerofpropenywhobuildsorimproveslherwn,and PERMIT ISSUANCE
whncommclsfur such projects with o contractors)licensed pursuant mthe Comrorms .K Il V
License Law. IN (' NJ FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this meson BACK FLOW P CT.
SANITARY Y N
Owner Dam 1 RECEIITp
DRAIN L i.: ,R C(
WORKMAN COMPENSATION DECLARATION SCIIpOI.'1'AX YN
• Wo em'Coma nsat Nalnsuv ccenifcnifiWcnmmmaf(Sce.39sta 0ra bC.)camof - RECEIPT
Workers'Compensmion Insurance ora ceniEed copy Hereof(Sec.3X00,LeM CJ which Fl .S-PER 00µK ME Y N
covers13 all employee's underthie permit. GAS-EA. - TLICI'S RIiCEI 'p
Policy# BUILDING DIV ION FEES
Company GAS-FA.SYSTEM OVIiR4(F:A) - PLANCHECK ME
❑ Certified copy is bercby famished.
❑ Cenllietl copy is lileA wish the city inspersion division GREASEJINDUSTRIi WASTE INTERCEPTOR GRADING FEB Al I
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS FEii
COMPENSATION INSURANCE
(phis section need not b,completed ifthe l'e+m,is forone hundred dollara(5100) SHWER-SANITARY-STORM P.200FT. EN EROY I'
drI sJ
(certify that in on in any ncmt'the
so as for become
subjepermito the Wlahall WATER fIEATF.µWNF.NT/ELfiCTµ
not employ any peon in any nt as m become subject m the Workers PAID
Z Cnmpenemion Laws of Cvlifomis. abate so WATER SYSTP.M/I'REATING a Recciplp
Applicant NEW RESIDI IAI,PLMB. S .IT.
C) Z NOlicant'O APPLICANT:If.eftvr making this CmiOcam of Exemption,you should Q TOTAL:
LI) becomesubject the Worker's Compensation provisiommfthe Lahor Code,youmust
7 fonhwilb comply with such provisions or Permit shall be deemed revoked. BUILDING FEE r.
1 [5 CONSTRUCTION LENDING AGENCY SEISMIC FEE
rte. Z Iherebyaffrm that there is a construction lending agency for the performance of
U C the work for which this perm it is issued(Sec.3097.Civ.C.) I 'TOTAL: ELECTRIC FEE
tenders Nome
•W F Lendux Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
-O U I certify that I have read this application and state that the above information is MECHANICAL FE
W coned Ingrcemcomply with all city and county oNinances end nuts,laws relating to PERMIT ISSUANCE
F" building construction,and hereby autbo8eerepresenwlives of this city menterupomhe CONSTRU(TIONT
U Z above-mentioned property for inspection purposes. ALT ER OR ADD TO MECI I.
M) gave,indemnify and keep hvMas the Cily of Cupertino againstcoslsundexpe seswhicIn may in any way accrue against said City AIR HANDLING UNIT(TO IR"CFM)
mingo Iht peat -
AIR HANDLING UNIT(OVER 10,000 CPM)
i
Sigamre of ApplicantlComragor ❑we EXHAUST HOOD(W/DUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE 'HEATING UNIT(TO 100.000 BTU) Datc roeipt g
Will the applicant m future building occupant store or handle hi urdous material
os deinM bythe Cupertino Municipal Cone,Chapter 9.12,and .01
the I IwIm and Safety HEATING UNIT(OVER 1000 BTU) TOTAL:
Code,Section 25532(a)'t VENTILATION PAN(SINGLE ROOD)
❑Yes ❑No
BOILER-COMP UHP OR IR),000 BTU) ISSUA C VQa8\
Will the applicant urfmurehuili ingoccupanr use equipmemordevoeswhichemit Y
ho animus air contamimmts asJe@rad by the Bay Area Air QualityManagementDistrict? BOILER-COMP(OVER 100,000 BTU)
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.IT. 1
/1 9"yy9/1�
I have read the haurdous materials requirements under Chapter 6.95 of the
``��T'
California l le:dlh&Safely Code,Sections 25505,25533 and 2553 .I undemland don
ifthe bnt oingdcesnmments currentlyhave
Must
be, that itis to issuanceofityrrificythe 16/
occupant of the tuino]mars which mull be mat prior ra issuance o of it Ccn notify
he
of
Occupancy.
Owner orawhmined agent Date TOTAL: ISSUED BY:�
OFFICE