26981 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO B.D.,11ni-F.EECTRICA PERMTTNO.
APPLICATION/PERMIT PLUMIIING-MECHANICAL 26981
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
D G UNIT# LOT
iRSN ME: af10N8: C RACTOR'S AMG: NO: N/C CONTROLp
w - 5a �n
RCHI'TECTI GINGER; LIC NO: A S: ❑
,I
'oNTACf: PHONE: QTY, ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ _C2_ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL lOB FSCRIPUON
O0Z Thereby of Division
i that 3 ofth licensed And irfomionsof Cade,
my Indng wiN ��
�s100 Section 7000)ofect. on 3 of the Business and Professions Code,end my li«nu is in pgNrpJ,g
ty full finecandeffecl, m
tQ,Z Licenu Class C.Ato UP T01 AMPS
Ilan GG bbbb:::: AMPS
Dale C CT'S Dr OVER
-IOW AMPS
s-m
ARCHITECT'S DECLARATION OVER IOp0AMPS Q�F1'.F1.00R ARTA E/SQ.FT.
oZyG lunderstand my plans shell be used as public records.
(:-.N.�� SIGNS ELECTRICAL
Q,j ,� Licensed Professional
NWIZ6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
OV F I hereby effort Nmi 1 exempt from Licensee Conclors License Law for Ne
W 3 O m following reason.(Seetion 7031.5,Business end Professions Cosic:Any city or«unry TEMP.MEE ER OR POLE INST.
1'tS« which requites a Proca m conswct,alter,improve,demolish,or repair any structure
prior to its iswane,also requires ma.pplicant for each permit to file.signedstatemem POWER DEVICES
[oslf pp��ap OC that he is licensed promart to the provisions of the Contractor's License Law(Chapter
LgeLL 9(commencing with Section]000) DvsionJof the Business and Pmfcuiom Cade) SWIMMING POOL ELECTRIC VALUATION
7W_w or that he is exempt Nereficarz a Misfor Neallegedexemption nyviolNon of OUTLETS-SWITCHES-FIXTIIRFS
ZQ Section 7031.5 by my.pplica 1 re rmn mbjectslhe. maavilpenilryof
G not mom Nan fiv hundred earl I. NEW RESIDENTIAL ELECTR S .PI'.
❑ I,us owner Apr t , employeesy' g he' olecompensetlon, —SQ.Pp. TYPE CONSTRUCTION
a3°-° will ao the work, t
to e s t' endedo� forsale(Sec.]044.Busiren.
Add Pmfeoions be amt nor'ea.icenseQa wd«s nal apply to en owner of
pmpenywhobui improve rco nd no does such work himself«through his
owncmployees,pro'it Nms tin emsafenolimeadeelmoffcrdforrohnIf, OCC.GROUP RES.UNITS
however,the builin rimprove cat is sold within one yearofcomplelion,the owner
builder will have the burden of that he did not build or improve for a 'TOTAL:
proving P purpose of
ilea).
[3I,uownero(the AmpsnY.emeaclusivelyconvnctingwithlicensed contr9emmlo QTY. PLUMBING PERMIT FEE ItOUD20NE APIA
Construct the project(Sec.7004,Business end Professions Coda)The Contractors PERMIT ISSUANCE
License Lawdoes nor apply mon ownerofpropertywho builds orimpreves Verson,and
whocomrucls for such projects with acuntrucums)licensed pursuant to the Convectors ALTER (PA) FEE SUMMARY
License Law.
❑ 1 am exempt under Ss. ,B&P C for this mason BACK MOW PROTECT.DEVICE 1 ITSJDFFEES
Owner Data SANITARY Y_N
RECEIPT#
DRAINg-FLOOR,ROOp,ARFA.COND.
WORKMAN COMPENSATION DECLARATION SCHOOL]'AX Y N
$J I hereby affirm Nm 1 have a cenifcule ofconsent laself-insort,«n cenificam of R[CBIPf#
(V ken'Campetssation lrmurunce ora cenifed copy Neuaf(gec.3800,Leb C.)wNch �� FIXTURES TRAP PARK FEE Y N
coven ell employee's under this permit. GAS-FA.SYSTEMd INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FLO
Company GAS-GA.SYSTEM-OVER 4(EA) PLANCHECK AEE
❑ Cettifiede.pyisherebyfumished.
❑ Certified copy is filed with the city inspection division. GREASIONDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASRTRAP SOILS FEE
COMPENSATION INSURANCE
(this AA.m. bAdmt be completed if Ne Permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200 p. ENERGY FBI!
or less)
Iceoy Nm in performance inmyinsid the work for which NiubjecPermit o the Wiser' WATER IiliSTER WNI3NT/GLECIR
not empty my Peron in any mnmtt so u m become subject m the Workers' Agip
Compcnxmi«laws mf Celifomie Date WATER$YSTEM/IRGATING Da¢ R«eiptp
C) NOTApplICE
should NEW RESIDENTIAL PLMIL SQ.PT.
C) Ncome subject
APPLICAorkersIf,.fter
Compensation
this Certificate of Labor Cru .you ou TOTAL;
r>r become subject to the Workers rs Camps or this provisiom of the Labor CWe,you run
a > forthwith comply wish each provisions or this pemdl shall be decmW rcvoted. BUILDING IIiE
UJ Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that there is a Construction lending agency for the perfommnce of
VO the work far which this pcmmit is issued(Be..3097,Civ.C.) BLECTRIC FEE
D. Lenders Name PLUMBING PEE.
0 U Undo.Address QW. MECHANICAL PERMIT FEE
1 trinity Beat 1 have read this aMfiestion and state that the above information is
26Correct.lugreem«reply with ill city and county rrdimncee end stem Iowa rcletingm PERMIT ISSUANCE MECHANICAL FEE
(A building constmemn,and hereby Authorize representatives of this city to enter uponthe
U 7 above-mentioned pmperty for inspection purposes. ALTER OR ADD TO MF.CI I. CONSTRUC'HON'fAX
C (We)agt«to save,.ndemNfy And k0hadmilaa Ne City of Cupertino against
liabilities,judgments costsandea, �h n yinanywayaccrue...innsald City AIR HANDLING UNIT(f010.000 CFM)
in conuqu ting of sp t. C
�/ AIR HANDLING UNIT(OVER 10,000C11M)
SipaldirlITApplihnInComot Data / EXHAUST MOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO BTU) Dale Receipt#
Will the applicant or future building«caper store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and Ne Health and Safety HEATING UNIT(OVER 100,00(I BTU) TOTAL:
Code,Section 25532p)R
Yes C1 No VENTILATION PAN(SINGLE RESID)
❑
Will the applicant orfuwre buildingescupanouequipmenlnrdeviceswhichemit
BOILER-COMP(311P OR 100,000 e"N) ISSUANCE DATE
intentions air contaminants as defined by the Bay Ana Air Quality Management
iBOILERCOMP(OVER IL ,000BTU)
slriclY .a -
-.
�. ❑Yes ❑No NEW RESIDENTIAL MECII. SQ.FT.
�1 have read the horardous materials requirements under Chapltt 6.95 of the NOV 28 1995
Cnlil'omi.Health&Safe,,Code,Sections 25505,25533 end 25534. 1 undersmnd Nm O a7
if iM1e building Aces of urrcmly nn fNat it is my respansibilu,m nintylhe
p m nl l y v¢nts c es t t prior to issuance of a Cerlificnte of tet',- VI' L✓rt'xa
" ,c%L ane/-o���3'S
Ownv rumboriud ag Dine TOTAL: ISSUED BY:
OFFICE