26432 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
, � BUIL1{NINGILPDRIOJE-CEIL'IEUCRTNR'fI INAICL ATION - PERMI'TNO.CITY OF CUPERTINO PLUMNG-MECHANICAL
BUILUINfJ DIVISION APPLICATION/PERMIT
26432_
BUILDINGADDRFSS: SANITARY NO. 1 APPLICATION SUBMITTAL DATE
UNIT# LOTH
le SN11: ^ PHONE: C TRACTOR'SNAMN/C JCONTROL#
• 011 F.Cf2NGINF.F:R: ,1 LIC NO: E' ❑
CONTACT: PHONE:
QTY: GLECI'RIC PERMIT FEE BUILDING PERMIT INFO
pLD)DQ r ELIiCf PLUMB MF.
PERMIT ISSUANCE T,I ❑
LICENSED CONTRAC'TOR'S DECLARATION APPLIANCES-RESIDENTIAL
mwzI hereb affimr that l am licensed under p (commencing 1 BDESCRIPTION
Pion y provision ionsC ter and mmencin m
�it00 Section 7000)of Division 3mf the Boniness and Professions Code,and my license is in PANELS
�kl full force and e[fcc
F ZU Ly 11icvrsc�Lia# 6PT02WAMPS
rn=y Date Conhacmr 2111-1066 AMPS
ZOyZ RCHITELTSDECLARATION OVER 1600 AMPS SQ.FT.Il,00R ARCA g/SQ.Pf.
O Z—❑ I understand my plans shell be used republic records.
rvn W SIGNS ELECTRICAL
Licensed Professional
1y'�Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
a�Meu I hereby affirm that 1 an exempt from me Curtail License Lew for the
ul3 to rn following mason,(Section 7031.5,Businessland Professions Code:Any cityormunty TEMP.METER OR POLE INST r
which requires a pumlil to construct,alter,improve,dernofish,or repair any structure
prions its issuance,also rectums the applicant forsuch pemrino file a signed statement POWER DEVICES
C
no that he is licensed pursuant to the provisions of the Contras is License Law(Chaplet
a oLL 9(commencing with Section 7000)of Division 3 of the Business and Professions Coded SWIMMING POOL ELECTRIC VALUA.LION��
I —Zn
or that 7011, mist by
applicant
l the permit slbeVshedexlicanto civiny l
of OUTLETS-SWITCHES-FIXTURES
FZa Section 7011,1 than by hundred
dollars($500), suhjects me applicant ucivil penally of
not tamethanfivehundreddollars yemp. NEWRESIDENT1ALELECIR _SQ.FT.
�' . ❑ L as owner and the opmy,ormyempinchadormwegnasthei(Sm. 0,s4,Bsiiess STORII3 TYPE.CONSTRUCTION
a3� anti Pr mework,and the he cture Colin not intLiccomrawdosnotoffined apply to an Business
and rdywsions ldsar The ves tmcmrs Licenx Law Jecs not apply m on owner of
own¢ ywyess,pdsodmprovufhcmogand whodo¢nsuch work himseered Il oogh If.
employees,pingoried] provemimpmvemrnthinnot eyourrdedmpletirW the owner-
builder e. OCC.GkOUP RFS.UNITS
huwcvea meave the hander ofproem ishat he idnot build or improetiun,purposef T L:
will have the burden of proving Thus he did not build or improve for purpose of
ate.). "
❑ Las r prosury. exclusively onlicensed mn'
QTY. PLUMBING PERMIT
F?-
E FLOOp_ZONE APN
construct the Project(Sc. 44.Businessand Professions with
he Commends
Licenxtrawdoapplyroanownerofpd , nd PERMIT ISSUANCE
wilt) metsfonsuchpmjectswith
cowmpomlicensed pursuant
toPoCommaemr'a
LicenseLaw. ALTER-D IN&VENT-WATER(I:A)
FEE SUMMARY
❑ I am exempt under Sm. ,B&P C for This rteaun BACK FLOW PR f. f. C ;� ' OUTSIDE FEES
I r ANITARY Y N
Owner Data I RECF.IPTp
DRAINS-FI.GO ROOPfARE" N .
WORKMAN COMPENSA'T'ION DECLARATION 7KrE
OOL TAX Y N_
❑ lherehy affirm metlhoveecenificnm oPoonsem to sdf-Ensure,orucenifcamof RECEIPT-
PAR Compensation Insurance m rseetifiN copy lhereof(Sec.3800,Lab C.)which FIXTURIS-PP.R AP YNcovers all employee§undenhis permit. GAS-EA. YSTEM-sT��AaA-M��BTLET$ RECEIPT#
Policy p Y/-kT L OUILDINCompany GAS-EA. , . :OVER 4(EA) NCHECK Fill!❑ Cmified copy is hereby famished.Certified copy is film with the city inspection division. GREASFANDUST'RL WASTE INTERCEPTORpING FEF:CERTIFICATF.OT EXEMPTION FROM WORKERS' GREASETRAP LS HE
COMPENSATION INSURANCE
(Thissemion nccd not he completed iflhe permit is fm one hundred dollau($100) SEWER-SANITARY-STORM HA.200FT. MGY FEE
'ales.)
I certify that in the performance ofthe work for which this permit is issued,I shall WATER HIATP.R WNENT/ELECTR
not employ any person in any m O as to become subject to the Workers' PAID
z Compensatienlnwsof Califomia. Dam o WATER SYSTEMMEATING Dam Rwcipt#
Applicant
� O NOTICE TO APPLICANT:LL after making this Certificate of Exemption.you should NEW RESIDENTIAL PLMB. SQ,IT. TOTAL:
0 become subject o the Worker's Compensation provisions of the Labor Code,you must
7 forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
Z CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that them is a construction lending agency for the performance of TOTAL: ELECTRIC HE
O the work for which mit this peris issued(Sec.3097,Civ,C.7
Leaders,Name O .�' families Address QTY. MECHANICAL PERMIT "FEE.
PLUMBING PER
U 1 certify that I have mail this city
and lou and stem that an above information minting is
correct. lagree
cama,mcomply larebylcityund county ordinances wJ stem lows relating a PERMIT ISSUANCE MECHANICAL PER .�
J fA hui.-rournsouction,aod heahspecti n prepmsematives of this city reenter upon the CONS'TRUCTION'FAX
U '� adw(We)agree p smst,.indemnify
inspection keep Incl ALTER OR ADD TO MECH.
(We)agree nt save,indemnify sad keep mama the Clry of Cupensts iguitar
If bilities,judgmenls,con¢endexpenxs which may in any way income against said City AIR HANDLING UNIT(T'010,(00 GPM)
mxyue meg mingn Nisp
AIR HANDLING UNIT(OVER 111.000 CFM)
Signatureof Applican4Com ucamDam EXHAUST HOOD(W/DUC)
PAID
HAZARDOUS MATERIAL DISCLASURB HEATING UNIT(TO 100,000 BTU) Duro Reeipt#
Will the applicant or future building occupant store or handle hazardous material ag
as defined by it,,Cupertino Municipal Coda Chapter 9.12,and the health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code,Section 25532(s)P
❑Yes ❑No VENTILATION FAN(SINGLE RESID)
BOILER-COMP(3HPOR 1118000 BTU) ISSUANCE DATE
Will car coricaductax a building byoccupanthBay equip Air Quality Management
p� p 4 D
zIdct? air amwminxH es defined by the Bay Arta Air Qualify Mxagemenf BOILER-COMP(OVER 100,000 BTU) Y- M
radical
"
❑Yes 0 N NEWRESIDI!NI'IALMFCII. SQ.t7. ■" Q I���
1 have read nu
the hadom
us axMAY riale requirements under Chapter 6.95 of he 2 6 1
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand that
if building docs not eumemly have a tenant,mart is my nesprdsibi lity to notify the C�}y 11 Us' VUr'Chlll
ceupant of the reyulrenmms which must be met prior m issuance of u Cenifwle of L
Occupancy.
Owner or amounted agent Dam ISSUED BY:
OFFICE