26420 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B li]-Lnlnc-I.1-F.LPRICAI. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL n C /I /�0
BUILDING PROJECIADENI'IFICAT'ION G v 4 L
BUILDING ADDRESS: p SANITARY NO. APPLICATION SUBMITTAL DATE
Z I G aN UNIT# LOIN
OWNERS NAME: PI NL•: CONTRACT'OR'S NAME: LICNO:
L1 2
IZU We CONTROL#
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT Fel? BUILDING PERMIT INPU
BLDG Fl ECT PLUMB MECIf
PERMIT ISSUANCE 1A El 0 El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDBNTLAI- �I JOB DPSCRIPT N
P400 IherehyollitmOaG3oftha. nsedinssand Professionshom
ewith Geese W ,. 1
.00 Section 7000)ofeDivisiont3 of the Business and Professions Code.and my licenseisin PANELS In QN
full force lass effect UPT0200 AMPS
onz Date Class Co
n#
m=y Dam Contractor 201-1000 AMPS
2.Oyz, ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O K-'n I understand my plans shal l he used as public records. /
Licensed
SIGNS ELECTRICAL
std Prol[sslOnal Cfk` I�'
E c'tyV OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. [ `� \ �_, I�,�' D I
x3�F I hereby affirm that 1 am exempt from the Contractors License law far the a ^ _
til Ow following reason.(Section 7031.5,Business and Professions Code:Any city or county TIME.METER OR POLE INST. (J.rt /]
F❑-Lyir ce= which requims a Permit m construct,ulter,improve,demolish,or repair any structure6 v u�(� 1
prioo its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
rt
that he is licensed pursuam m the provisions of the Commcmea License Law(Chapter
ggo6' 9(commencing with Section 7")of Division 3 of the Business and Profusions Code) SWIMMING POOL ELECTRIC
X_ce or Nat he is exempt hercfmm and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
trG Section 7031.5 by any applicant for a Permit subjects the opption,to a civil Penalty of
not mom than five hundred dollars($5W).
td $ ❑ I,asownerofNepmpeny,ormyemployceswi,hwugesmtheirsolerompensatlon, NRWRESIDPNTIALELECIR _SQ.FT. STORIES T PF.CONSTRUCr10N
q3,., will do the wnrk,anJ the strncwre isnm imendedornl Tercdfar safe(Se,7044,1usinew
omd Professions Code:The Communes License Law does not apply to an owner of
property who buildsorimproves thereon,endwh.d.x such work himselforthmugh his OCC.GROUP NES.UNITS
ownemployees,providcdthauuch improvermntsarenot inlendedoroffeted forsale.If,
howeventhe building.rimpr.vetmnt is sold within one yemafcompletion.the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,asowner(tribe progeny,am exclusively commeting with licensed contractors to QTY. PLUMBING PERMIT FEF: FLOOD ZONE APN
exammuct the project(Sec.7044,Business end professions Code:)The Contractor's PERMIT ISSUANCE
License law doesma apply to an ownerofpropeny who builds or improvesihemon,and
who contracts mrsuchprojects with o contmcrems)licensed ptnmerat tothe Commors
License Law. ALTER-DRAIN&VEST-WATER(BA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FE
SANITARY Y_N
Owner Date RECEIPT M
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,RUDE,AREA,COND. SCHOOL TAX Y N
❑ I hereby affirm that l have averificamofemound,oself-inure,oraccnificmeofFTXTpBE$.PER TRAP RECEIPT'#
Workers'C.mpensation lrssumnceoracerifiedcopythereef(See.3800,Lm CJ which PARK FEE Y N
oven all employee's under this pemtit GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FECS
Company GAS-EA.SYSTEM-OVER 4(FA) PLANCHECK FET:
❑ CedilieA copy ie hereby furnishuf.
❑ Cenitied copy is filed with the city inspection division. GREASB/INDUSTRI.WASTE.INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
CUd,section need..,becomplued ifthe permit is far one hundred dollars($100) SEWER-SANITARY.STORM F.A.20017. ENERGY FEE
or less.)
I cenily that in the performance of the work for wh lch this permit is issued,l shall WATER HEATER WNBNT/ELEC'TR
not employ any person in any manner so in to become subject to the Workers' PAID
Compmmi(tnlawsof CaliSmd.. Date WATER SYSTBMnREATING pate Receipt
Applicant
z�7P0 NOTICE TO APPLICANT,If,slier makingthis Certificate of Exemption,you should NEW RESIDENTIAL ELMS. SQ.FT. '1'O'AL:
Frt V) became Subject to the Workerm
Workers Compensation provisions of the Labor Code,you must
lei fonhwi,h comply with such pmvi sins 13I11LDING FEE or this permit shall he deemed revoker. �r
[a CONSTRUCTION LENDING AGENCY SHISMIC FEE
7 z I hereby offtrm that them is a consmstion lending agency for the performance of TOTAL: ELIiCfR1C FEB
U p the work for which this permit is issued(Sec.3097,Civ.C.)
� Lender's No.
No. a PLUMBING FEE
Lender's Address Q'I'Y. MECHANICAL PERMIT' FEL
1 certify that I have read this application and pmC that
LkI aboveinformation is
comet, le agree mcom comply all city county yordiastases and om laws mining m
PERMIT ISSUANCE MCCIIANICAIEh
ybuilding construction,and hereby sulmnia representatives ofdoiscity to enter upon the CONSTRUCTION TAX
V Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep hamdess me City of Cupertino against
I iuilam.e dmsents,rosus andaxpema which may in any way accmeagains,acid City AIR HANDLING UNIT CTO 10,000 CFM)
incon uenceofthe gm mingofthispem,it.
AIR HANDLING UNIT(OVER BI,M)CFM)
SVia
i a of AppliewdoCommctnr )ate EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IOT000 BTU) Date Receipt#
Will the upplicaat or future building occupant store or handle hamrdom material
m de toed by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HFATING UNIT(OVER 100,000 BTU) TOT 1.:
Cale,Scott 25532(e)
0 'f Yes 11 No VENTILATION FAN(SINGLE RHSID)
Will the oppliuntnrfuwrc buildingocCupant useequipmcnmrdevices which must BOILER-COME(3HP OR 100,000 BTU)
ISSUANCE DATE
haaardous lir contominsats m dented by the Bay Arca Air Quality Mamgemen,
District? BOILER-COMP(OVER 100,1000 BTU)
❑Yes ❑N. NEW RESIDENTIAL MECH. SQ.Ff.
I have mail the Immunities materials requirements under Chapter 6.95 of the O
Celifomia Hwlth&Safety Code,Sections 25505,25533 and that
25534.1 understood
if the building does no,conically have a terunt that i,is my responsibility to notify the
occupant ofthe requirements which must be met prior to issuance of u Ccnificate of
Oseapaney. V
Owner or umbnriaed agem Date TOTAL: ISSUED B'
OFFICE t urthlu�U