26209 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 'DINT: F.LELTRICA, PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. v C O A
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION J
BUILDING ADDRESS: SANITARY NO. APPI.ICRI ION SUBMI'I'I'At,DATE
IN3 a(� I UNITN LOT �2
'NAME: �� PHONE: C RACFOR'S NNAMME�:+ 2�/: N/C CONI KUL,0
ARCH [C' ENGINEER: LIC NO: ADDHB. .f. S Fac
CONTACT: PHONE: 'I
QTY, ELECTRIC PERMIT FBI? BUILDING PERMIT INFO
PLDG ELECT PLUMB MECH
PERMIT ISSUANCE a❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
QWz Ihereby affirm chat l am licensed underpmvisionsofaapter9(commencing with
F300 Section7")of Division 3 office Business and Professions Code,end my license is in PANELS
yy� full force and effort.
Q_ IIP TO 200 AMPS
F License Chas Lie.
y y
Data Cnntrucror 201-1000 AMPS
ZOyZ ARCHITECTS DECLARATION OVER IOOOAMPS SQ.FT.FLOOR AREA S/SQ.Ff.
O Z n I understand my plans shall be used as public records. II SIGNS ELECTRICALLED
IN
4 Licensed Professional
Lg OWNER-"amps fresh
RDECe CommiON SPECIAL CIRCUIT/MISC. t
O a I hereby affirm that I.rat exempt from the Committees License Inv for the yl
3LLyQ (allowing resume.(Section]Ol LS,Business and Professions Code:Any city or county TEMP.METER OR POLE MST. A
F J which regain,n permit m comment,acre,improve,demolish,cer repair any swcmm 7
y}� pHe,mI's issmme,.IsoingmmestheapPlicam for Loch Permit 1.fill.sitcom mmment
ePOWER DEVICES
<O 'bathe is licensed pursmnt to the provisions of the Contractor's License Uw(Chapter
LMa4a�' 9(commencing with Section 7")of Division 3 ofthe Business and Profusions Code) SWIMMING POOL ELECTRIC VALUATION
Www .,that he is exempt therefrom and theb.gistoftheallegedexemp cur.Any vio.tionof OUTLETS-SWRCHFS-FIXTURES
z Q Section 1031.5 by my applicant for a permit subjects Lie applicant to a civil penalty of
nm mart chin five hundred doIlma($5W). NEW RESIDENTIAL ELECfR S .FT.
❑ 1,.sownerofthepropeny,ormyemployeeswiN wagesas theiraolecompcnsation, Q STORIES TYPE CONS'BUCHON
p, will do(lie work,andfhe Stmcmmisna intcndeloroffered forsale(Sec.7044,Business
.nil Professions Code•.The Contractor's License Law does not apply to an owner of
pmpenywho builds.rimprma themon•andwhodcessuch work himselfer dunughhis
wnemployees,providedthat such imprivementsarenor intendedaoffered forsale.If, I OCC.GROUP RES.UNITS
however,fhebrilding orimprovcmem is sold within one your of eemple'ion.the owner- TOTAL:
builder will have the burden of proving that he did nm build or improve for purpose of
sale.).
❑ [.us owner office property,amexclusively contracting with licensed wouacd.rsto QIY, PLUMBING PERMIT FEE FLOOD UNL APN
Mastered the project(Sec.7044,Business and Professions Code:)The Conuactora PERMIT ISSUANCE
License Law does not apply m m owner of property w ho ba i Ids on ime provtherein,roil
who contracts forsuch projects with a conformists)licensed Innocent o the Conuaaors ALTER-DRAIN&VENT-WATF.R(EA
Liccnw Law. ) FEE SUMMARY
❑ 1 aciexempt ander Sec. ,B&PC for this reason BACK FLOW PROTECT.DF?VICE. U'f 1
SANITARY Y N
Owner Date RECEIPTp
• DRAINS-FLOOR,ROOF.AREA.COND.
WORKMAN COMPENSATION DECLARATION SCI100L TAX Y N
❑ Ibembyaffimmhailhaveacenificateofcmre nn(iself-insum,.ramnificateof RECEIPT
Workery Compensation Insurance as certified copy thercof(Sec,3800,Lab C.)which FIXTURES-PER TRAP PARK FEE YN
Movers all employee's under this permit GAS-PA.SYSTIiM-i INCA OUTLETS RECEIITN
Policy p BUILDING DIVISION FEES
Company GAS-C•A.SYSTEM-OVER 4IRA) PLANCHECK FEE
❑ Cmifred copy is hemby famished.
❑ Certified copy is filed with the city inspection division. GRBASEJINDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE.TRAP SOILS FEE
COMPENSATION INSURANCE
flfiisseed.London,bmmplaed if Ne permit is Toon hundred d.1t.($IM) SEWER-SANITARY-STORM EA.200111'. ENERGY FEE
or less.)
I certify that in the performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ my pawn in any manner so as to become subject in the Workers' PAID
z Cluen,me'iomiswsof C.lifmmia. Date WATER SYSTEM/TREATING
O Dare Receipt
Applicant
NOTICITO APPLICANT If.after making this Cerifethe offoampfion,you should NEW RESIDENfIALPLMB. SQ,FT. TOTAL:
O
fq become subject o its,Workers Compensation provisions of the Labor God.,you most
a forthwith comply verb such provisions or this pernitsball he deemed revoked. BUILDING FEE
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
z
C, Ihereby affirm that them is a construMfion lending agency for the performance of
U The work for which this Permit is issued(Sec.3097,Civ.Cd A ELECTRIC FEE
Lenders Name
w0F Lenders Address QTY, MECHANICAL PERMIT FEE PLUMBING FEE
U 1 cmily that 1 have end this application and store that the above information is
>> a comae,.l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
y buileingcormrcdion,and hertbymthaim representativesofthi.eiy to enter upon the
U above-mentioned mi profor inspection puposea. ALTER OR ADD TO MECH. CONSTRUCTIONTAX
(We)agree to save,indemnify and keep harmless the City of Cupertino against
111bor'es,jnd ems.costa nn sus which may many way accrue against said City AIR HANDLING UNIT(1'010,000CFM)
m
in Moeco ago fthu id.
AIR HANDLING I IT(OVER 10,000 CFM)
i
awrc of nplicarficWdumchor D e EXHAUST HOOD(WNUCr) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(T0100,000 BTU) Date Rcecip'N
Will the applicant or(mart building ocnpm'sort or handle hazardous materiel HEATING UNIT(OVER 100,.00 BTU) T
u defined by the Cumin Municipal Cedan
Conn.Chapter 9.12,and the Huth d Safety
Code,Section 25532(.)7
❑Yes El No VENTILATION FAN(SINGLE REXD)
Will theapplicantor fumrc building xaupanr use equipment ondevicee which emir BOILER-COMP(3HP OR 1011,000 BTU) ISSUANCE DA
hassNous air communities as defined by the Bay Arca Air Quality Mamponam BOILER-COMP(OVER 100,ON BTU) Pik ;El Yes Cl No NEW RESIDENTIAL MECH SQ.FT. /1fs/s
1 have read the hamfdous materials mquireamems under Chapter 6.95 of the '�/q� (�
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand Nor 161 par
if the building don not curemly have a Rnant that id's my responsibility to notify the cocupa ttcof the requirements which must he ma prion to issumce of a CeniGcme of Ur f r
occupant
ua I1V
Owner a ntnhorlud agent Data TOTAL: ISSUED BY:
OFFI