26737 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY '
CITY OF CUPERTINO APPLICATION/PERMIT iia PLUBUIMBINLD G-MECHANICAL. PERMIT NO.
BUILDING DIVISIOISIO N BUILDING PROJECT IDENTIFICATION 26737
BUILDING ADDRESS: SANITARY NO. APPLICATION
SUBMITTAL DATE
UNIT# LOT#
OWNERS AMF.: PHONE:
RACX'S NAME: LIC NO:
N/C CONTROL#
•ARCHITE INEE LICN S: < �� ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT P UMB MECH
PERMIT ISSUANCE El 0 ❑
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DESCRI ON
pa�z Iherebyaffirmthat lam licenud underprovisionsnfChapter9(cotrunencingwiN
00C Sceion]O(p)of Division ofihe Business and Professions Code,and my license is in PANELS
,UE full farce and effe UPTO200AMPS }\
F Z License CI Lic,k
rn=y Dure Contrecmr 201-1000 AMPS
Z O--7a RCHITECTS DE A A N OVER 1000 AMPS SQ.IT.FLOOR AREA $/SQ.FT.
O z_G 1 understood my plans shall be used as Public records.
i4l" SIGNS ELECTRICAL
i Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/1NISC. 'r - --�
OaF 1 hereby effrm that 1 sm exempt foam the Contracmre License Law far the (/,�� pI 11��r
W 3Ow following mason(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE MST. \ A Lam. I' IHl Ipl\Vp
so rn which requires a permit to construct,alter,improve,demolish,or repair my structure
C Q� forum its issuance,also requires theapplicmr forsuch pennittofileesigned statement POWER DEVICES i ✓�� 1 �� E
`y R that he is licensed pe rsuanuo the provisions of the Contractor's License Law(Chapter J �.d
L ala, 9(wmmeneing with Section]BOO)of Division 3 ofthe Business and Professions Cade) SWIMMING POOL ELECTRIC XA ON
or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURESUAIlzC
F�Q Section 7031.5 by my applicant for a permit subjects the applicant m a civil Penalty of
'� O not more than five hundred dollars($500).
u��m ❑ I,asowneroOheproperry,ormy<mployeeswithwageses lheirsolecompmsetion, NEW RESIDENTIAL ELECTR _SQ.PT. STORIES TYPECONSTRUCTION
aa--• will do the work,andthesoucmre isnot inteadedoroHered for sal]044,Busioess
and Professions Code:The Convector's License Law does not apply an an owner of
propertywhobuildeorimpormad emom,andwhodaessuchwork himselfor through his
wnemployees,providMthatsuchimpmvementaarenotimendedorofferedforsale.If, OCC.GROUP RES.UNITS
however,the building orimprovement is sold within one yearofcompletion•Neawner- TOTAL:
builder will have the burden of proving that he did nor build or improve for purpose of
aale..
❑ I,asowmerufthepropevy,amexclusivelyconvacdngwimlicensedcmatracmmtm QTY• PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7014,Business and Professions Cade:)The Contrecmr'e
License Law does not apply to anownerofpropely whobuildsorimprovesmemn,rod PERMIT ISSUANCE
who contracts formsh projects with acontrachoran licensedpursuan[mthe Comlracmr's ALTER Law. WATER(EA) FEE SUMMARY
❑ I am exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE - OUTSIDE FEES
SANITARY Y_N
Owner Date DRAINSFLOOR,ROOF,AREA, RECEIPT#
-
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
• ❑
Workers
Compensation
Insuance ori0ca¢ofconsentmse(Sm.re.Br Lab C.)matirwhich FIXTURES-PER TRAP RECEIPT#
Workers Compeneationler thiscearaceri0ed copy thereof(Sa.3600,Lab C.)which PARK FEE Y N
covers toll employee's under this permit. GAS
Policy SYSTEM-I INC.4 OUTLETS RECEIPT*
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4 EA
❑ Cerified copy is hereby with
the city ( ) PLANCHF.CK FEE.
❑ Ceri0cd copy is filed wiN Ne city inspection division. GRE.ASEANDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS HE
COMPENSATION INSURANCE
(This section need not be completed iflhe pemritisforeem hundrddollas($IW) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.
I certify that in the performance of the work for which this Permit ax Priced,l shall WATER HEATER W/VENT/ELECfR
not employ any person in my manner so as to become subject to the Workers' PAID
Compensation Lawsof Califomis. Date WATER SYSTEWREATING Date Receipt
Q ,Z Applicant
Z O NOTICE TO APPLICANT:If,after making this Cedficate of Exemption,you should NEW RESIDENTIAL PLMB, SQ.FT. TOTAL:
F' 4 become subject to the Worker's Compensation provisions of the Labor Code,you must
a > forthwith comply with such provisions or this permit shell be deemed revoked. BUILDING FEE
pal, z CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a commuction lending agency for the performance of
U O the work for which this permit is issued(Sec.3097.Civ.C.) ELECTRIC FEE
Lenders Name
OU Lender's Address Q'T'Y, MECHANICAL PERMIT FEE PLUMBING FEE -
LkI 1 certify that I have read this application and amts that the above information is MECHANICAL FEE
correct l agree to comply with ell city and county ardinmces and state laws relating m PERMIT ISSUANCE
y building construction,and hereby authorize representatives of this city to enter upon the CONSTRUCTION TAX
U 7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
•7 (We)agree m save,indemnify and keep harmless the City of Caption against
liabillues,ju tots,costs dexpenseswitth imenywayarameagairstmid City AIR HANDLING MIT IB,"CFM)
conuq a of t g of this
AIR HANDLING U141T(OVER 10,000 CFM)
iy amts of ppbcant/Contmct EXHAUST HOOD(W/DUC I
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,(101)BTU) Dare Receipt#
Will the applicant or future building occupant store or handle hazardous mamdal
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IOq(g0 BTU) TOTAL:
Code,Section 25532(a)1
El Yea 0N VENTILATION FAN(SING LE RESID)
Will the alonoanmrfls as defined
occupantuse Area it Quality whichemit
BOILER-COMP(3HPOR 100,00)BTU) ISSUANCE DATE
haraMous air comaminmts as defined by the Bey Area Air QaNlly Management BOILER-COMP(OVER IW,000 BTU) n p 0
.� District? Y- /i
Dyes ❑No NEW RESIDENTIAL MECH. SQ,IT,
I have read the hazardous materiels requirements under Chapter 6.95 of the ��� 1 19
California Health&Safety Cade•Sections 25505,25533 and 25534.I corrosion at
I JY
if the building does not currently have a tenant,that it is my responsibility to notify the
cf the requirements which musrme msom
be prior isce of a CeriMate of
Oupceupasanc oreqemGill
f V
Owner or emhorzed agent Date TOTAL: ISSUED BY: