26258APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE SALL POINT PEN ONLY
CITY OF CUPERTINO UZIll a- . r I AIPERMITNO.
OAPPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING Its II LIM Ne: PRO WITP I BEN9'IFICATION
26258 nCO
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l."Ito-.1oriv o'con: L1LryV:
OUTSIDEFEES
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
2 7 2'7
PERMIT ISSUANCE
Y N
LICENSED CONTRACT'OR'S DECLARATION
APPLIANCES - RESIDENTIAL
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Ihereby affirn that l am licensed under provisions of Chapter 9(commencing with
Secllent7 00)mf Envision 3 of the Business soil Professions Code, vad my license is in
full force and efface.
PANELS
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License Clans Lic.Jr
Date Contractor
UPT02MAMPS
201-1000 AMPS
ARCHITECTS DECLARATION
1 undentund my plans shall :used us public records.
OVER IME AMPS
SIGNS ELECTRICAL
Licensed Professional
ENERGY FEE
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p�3u-y
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OWNER -BUILDER DECLARATION
1 hereby affirm that 1 em exempt from the Cotnmctor's License Law for the
following reason. Section 7031.5. Business and Professions Code: Any city or county
which requires a permit to construct. alter, improve. demolish, or repair any structure,
print to its ismance,also requires theapplicant for such permiuo filen signed smmmem
that he is licensed pursuant the provisions of the Commeco's License Law (Chapter
9(commencing with See ..7").1 Division Sof the Business and Professions Code)
or that he is exempt therefrom and the basis for the alleged exemption. Any violation
Section 7031.5 by my applicant for a permit subjects the applicant macivil penehyo
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRICdno�
UTLEfS- SWITCHES - FIXTURES
237,
�K L
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nm more than five hundred dollms ($500).
❑ LmOwmrk,a eh epstruct,ormycmpewiffer georands(Sm.7ompenmdoa.
will do thework,Code: as
ercoesnot
intendedse
NEWRESIDENTIALELECfR _SQ.IT.
he Cmdls.oe
not to m o ler of
LA m Cn owner of
and Professions Code: The Contmceor's License law apply
property whoes, Idaorimpmveu ah such hime
whodocs such work NmuIfedthough his
Imon,end
own employees,providedthat menet intendedreofferedforrole.
—
improvement soldwit fm, the owner-
or
emem iahat did..
huilder,Ne:dd s,brden
uildyea
improve
builder will hev<the burden of proving that he did nee build or improve fm purpose of
of he Imposef
QTY. PLUMBING PERMIT FEE
cele.).
❑ Lm corseting with
ofthe pm.
Cma:oudcontnaomo
theowner
70,1 , Business end Professions mune The Coetracmr's
an
Licensee the project (Sec. to owner of
License Law does not apply eLi en owner of property who builds m improves thereon, and
PERMIT ISSUANCE
whoconeraces for such pmjmts with acontrmtor(s) Iicenoul pursuanuo the Contrerm's
License Law.
ALTER -DRAIN&VENT - WATER (EA)
❑ 1 em exempt under Sac. , B & P C fm chis ream.
BACK FLOW PROTECT. DEVICE
Owner Data
DRAINS- FLOOR. ROOF, AREA, COND,
WORKMAN COMPENSATION DECLARATION
FIXTURES - PCR'fRAP
❑ Ibercby eflirm Natl:ve ucenilicae of consemmself-insure, oracertificvte of
Wor:ri Compensation Insurance or v certified copy, thereof (Sm. 38M. Lab C.) which
GAS - EA. SYSTEM -1 INC. 4 OUTIAT
covers ell employee's under this permit.
Policy a
Company
GAS - EA. SYSTEM -OVER 4 (FA)
❑ Certified copy is hereby famished.
GREASRANDUST'RL WASTEI
ffiqW
❑ Cenifed copy is filed with the city inspecniandivisian.
CERTIFICATE OP EXEMPTION FROM WORKERS'
GREASE. TRAP
COMPENSATION INSURANCE
SEWER - SA RM
(ITisseclionnudnut be completed if the permit is for one hundred dollars(SIM)
or loss,)
WATERT T W/VEMTELECTR
Icmify Nat in the perfonnarrat the work (a, which,hia person is issued, l0all
ar so as In become subject to the Workers
not employ troy person in any counter
WATERS ST RCA
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ZP
Compenaaion Lawsof Culifomia. Data
Appl e.,
NEWRFSD-
NOTICETOAPPLICANT:ILafmrmakingthis Cenificamof Excmption,youshauld
FEn
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,r
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0 C1
s?^ ikl
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become subjecuo the Workers Compensation provisions of the labor Code, 1.must
fnnhw'nh comply with such provisions or this Pirie shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the pertormantt of
Ne work for which this permit is issued (Sm. 309], Civ. CJ
Lender's Name
TOTAL:
-
QTY. `tMANICAL PERMIT FEE
Lender's Address
I cmify Nm I hav�udblt pP maria. end state the alcove information is
acnes. ICgre oply Mail 11"Y'
ity vnd coumysordinence and stmelCwa relatingm
building strgaian, and hcrcby emhoris mpresene' ofehiscitymrnterupon Ne
a:v emionedpropen fori 'oiaPa
PERMIT ISSUANCE
ALTER OR ADD TO MECILqc1.
ti
o save, indemnify cod keep harmless the City of Cupertino against
li it .costsodexpenuawhich may in my way acemeagvinse mid City
AIR HANDLING UNIT (TO It." CFM)
consequrnce of the ting aphis Permit.
AIR HANDLING UNIT (OVER IO,OW CFM)
EXHAUST HOOD[W/DUCT)
Si inure of Al,irm/Cont:mr Date
HEATING UNIT (TO IM." BTU)
IfAZARDOUS MATERI SDISCLOSURE
pliant or future buildin sent mom or handle hauNous maeedal
esdcfir¢dbye a ape no uninpe CM,.Ch.p¢r9.12,..d Neli.ith.d Safety
HEATING UNIT( OVER 100,000 BTU)
VENTILATION PAN (SINGLC RESID)
Code, Section 25532(x)'1
❑ Yes ❑ No
BOILCR- COMP (311P OR 100,000 BTU)
Will theupplicwtmrutumbuildingoceupantuuequipm tordevices whichemie
BOILER- COME(OVER 100,000 BTU)
ah c.mvminants in, defined by the Bay Arca Air Quality Management
ohamrdom
District
NEW RPSIDFNTIAI. MECH. SQ. PT.
f I ❑ Yes ❑ No
1 have read the hocaudous materials reyuirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505.25533 and 25534. 1 understand that
if the building does not currently have a tenant. that it is my responsibility to notify the
occupant of the rtquiremems which must be mat prim m issuance of a Cmifcum o!
Occupancy.
Owner or authorised agent Date
L -J
0
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
PAID
Dam
PA 10
NO m
FEE SUMMARY
OUTSIDEFEES
SANITARY
YN
RECEIPT M
SCHOOL TAX
Y N
RECEIPT p
PARK FEE
Y
RF.CI:tPI'
BUILDING DIVISI FEES
PLANCHECK TEF.
GRADING FEE
"ILSFEE
ENERGY FEE
PAID
U: a
cccivtp
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
PAID
Dam
PA 10
NO m