26953 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO .- " MI
PERTNO�
APPLICATION/PERMIT PLUMBING-MECHANICAL /�C � C
BUILDING DIVISION BUILDING PROECI'IDENTIFICATG
ION o J
BUILDING ADDRESS: f SANITARY NO. APPLICATION SUHMITTAL DATE
UNIT# LOT# N�
O N MI?: PHONE: C R'S I KD( N/C CONTROL#
-�A 1 UDEN N ER: LIC NO: ADD • '..J^�� El PHONE: 1 say BUILDING PERMIT INF
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMV MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
I hereb aHumthat l smlicaraed under p ( gw' JOB DESCRIPTION
pK2 Y provisions of Cha ter9 cammencm mth
1-00 Section]000)of Divisi0n3 of Ne�stsiness and ProfessionsC sad my license is in PANELS
y�+� full force undef gc -Cj'y �oL�/TI/ UP TO 200 AMPS
GF-Z Ise License lass LICK IJV
N=yData Contractor 201-]"AMPS
ZOrV'xm3 ARCHITECT'S DECLARATION OVER 1000 AMPS - SQ.PI'.FLOOR AREA $/SQ.PI'.
0 Z_ ]understand my plans shall banned m public records.
F ~� SIGNS ELECTRICAL
Qy$'J Licensed Professional
sa�aad4K�V OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
[v109!U I hereby affirm that I am exempt from the Contractor's License Law for the
following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR TZ INST,
which requires a permit to comarm t,alter,improve,demolish,or repair any atructum
;�(Y•� pont to its issuance.050 rcquues the applicant fox such Permit to file a signed statement POWER DEVI
pj�00 that he is licensed purxuanno the provisions of the Contracture Licras law(Cbepter
a Ke� 9morommnciag with Section]OW)of Division 3ofthe Business and Professions Code) SWIMMING LELECIRIC VALE
�TfpN
yl_y or he is exempt and the basis for thealleged exemption.Any violation of /Doe I
Q
Section 7031.5 by any upplicatn for a prmmit subjects the applicant t0 a civil penalty of OUTLETS-SWITCHES-FIXTURES
C e, not more than five hundred dollars($500).
❑ I,asownernOheproNny,ormyemployeeswithwegesactheirsolecompensstion, NEW RESIDENTIAL ELECTR ESQ.Ff. STORIES TYPECONSTRUCTION
6 — will do the work,and the slmcturcis not intended oroffertd frande(See.7(*1,Business
and Professions Came:The Contractors License Law does not apply m sat owner of
pmpmy whobuildsorimproves thereon,and had.such workhmeselforthroughhie
ownemployas,pnwidedthatsuchimpmvc=tsa mlintendedorofferedforWe.It, OCC.GROUP RES.UNITS
however,the buildingor improvement is sold within one yearofromplation,the owner- TOTAL:
builder will have the burden of proving that he did net build or improve for purpose of
le.).
❑ I,as ownerofthe property,am exclusively contracting with lirmsedcontracmrs to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
convect the project(Sec.7044,Business said Professions Conde:)The Contractor's
Licenselawdessam applyt0en ownerofpropeny whobuilds eximpmveadvarmn,end PERMIT ISSUANCE
whornamects forsuch projects with acontractor(s)licensed pursuant to the Convectors
License Law. ALTER (FA) FEE SUMMARY
❑ Lam exempt under Sec. F_,B&P C for this reason BACK FLOW PROTECT,DEVICE OUTSIDE
SANITARY YN
Owner Dme RECEIPT p
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOLTAX Y N
❑ Thereby affirm thmlhave acenifcmabf coraem to self-imurt.oracmificam of RECEIPT#
Workers'Com naatioulnsurvtceora crnifiedc FIXTURES-PER TRAP
pe copy therca((Sec.3600,lab O)which PARK FEE Y N
ars all em Ipyee' gratis a '/ GAS-LA.SYSTEM-I INC.40UTLETS RECEIPT'#
polis" 'C— ` BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(M) PLANCHECK FEE
❑ Certifed copy is ereby famished. a -
[L.C.1fifiedcopy isfiled with the city inspecnondivision. 1 GREASPIINDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIMCATEOFEXEMPIItforich
O REASCTRAP SOILS FEE
COMPENSATION 1
(This section rteed notbe completed ifthea ollvs{$IBb} SEWER-SANITARY-STORM 6A.200FT. ENERGY FEE
or less.) 11x
Icmify that in the performance of the woio pe is ued, shall WATER HEATER WNENT/ELECR
not employ any person in say manner so aso the Workers PAID
0 Z Compensation Luwsof California. Date WATER SYSTEMf REATING Data Receipt#
Applicant
Z NOTICE TO APPLICANT:If,after making this Certificate of Exemptim,you should NEW RESIDENTIAL PLMB, SQ.FT. TOTAL:
fbecome subject to the Workers Coe,mantium provanom of Ne Lauer Cade,you must
> forthwith comply with such Provisions or this pemat shell the domed revoked. BUILDING FEE
W
z CONSTRUCTION LENDING AGENCY SF715MIC FEE
^a 1 hereby affirm that there is s construction lending agency for the Performance of TOTAL: ELECTRIC FEE
V O the work for which this Permit is issued(Sec.3097,Civ.C.)
(-r Lender's Name
l—' Lenders AddressQTY. MECHANICAL PERMIT PEE PLUMBING FEE
L) 1 certify a m 1 have rand this application end state that the above infor information is
correct.l agree to comply with ill city sand county ordinances said state laws relating to MECHANICAL FEE
PERMIT ISSUANCE
r 1A buildingeonstruction,and hereby authorize mpresenadvrsofthis city to enter upon the
L) `1 above-mentioned prapeny for inspection purposes. ALTER OR ADDTO MECH. CONSTRUCTIONTAX
L7 (We)age to save,indemnify and keep hafmless the City of Cupertino against
Iisbilities,judgments,costs andexpereas whichmey in any way acaueagainst said City AIR HANDLING UNIT(TO 10,050 CFM)
in consequence of the grounding of this Permit.
AIR HANDLING UNIT(OVER EL"
Signature of Applica t/Convector Data EXHAUST HOOD(W/DUC I PAID
I IAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO HE
.094TU) Dme Receipt#
Will the applicant or future building occupant store or handle hazardous meteriW
as HEATING UNIT(OV 100,000BN)
defined by the Cupenin0 Municipal Code,Chapter 9.12,and the Health and Softly
Cade,Section 25532(a)T
❑Yes &Ne_� VENTILATION (SINGLE RESID)
BOILER-CO PQHPOR 100,000 BTU) ISSUA�CFs,DAT"
Will the ncontrudrants s building by mummery Amu
Quality Mmachemic
hazardous air caintuminunm as defined by the Bey Arcu Air Quality Management BOILER- MP(OVER W,(A'Ifl BTU)
Dievim? /
❑Yes `].IQ NEW R IDENTIAL MECH. SQ.FT. FEB 9
I have read the hamrdous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,M533 and 25534. Iunderstood that CITY J" weal
if the building dues t currently have a mount,that it is my resm ponsibility notify the
occupant of in ovem.whi,�mum he met prior to issuanceyof a Ceni ical
Own%rco�r�eu(ihonagem Dem TOTAL: ISSUED BY:
OF C