26369 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO R°"DING-ELM ERICA- PERM[I NO. 26369
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUIL-DING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS:1 SANITARY NO. APPLICATION SUB/MM Al.DA'IE
LOT#
OMF, PHONE: CONTRA 'S NA r LIC NO: ll
/x NIC CONTROL#
IARCHITECT/ENGINEER: LIC NO: ADDRESS: ElCONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG
E Cf PLUMB pll?CI(
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
mwz Ihereby affirm that l am licensed underpmvisionsofChapter9(commencing with JOB DESCRIPTION
�rs00 Section 9000)of Division 3 ofthe Business and Professions Cade,and my liwnw is to PANELS
K V E full force and cffeet.
IQ.,Zw License Class Lic.# UPT0200AMP5 • , r M/
m6y Ilse Cantracmr 201-1000AMPS
I'-,z ARCHITECTS DECLARATION SQ.FT.FLOOR AREA S/$Q,FT,
O ec— 1 understand m plans bell M used az public recoMs. OVER ELLHXX AMPS
0, n my s
F ec F W SIGNS ELECTRICAL
�J l icenxed Professlnnul
OWNER-BUILDER DECLARATION SPECIAL CIRCUTHMISC.
iCO6F 1 hereby affirm that I am exempt from the Convaeww's License Law for the
FLLOwQ fnllowingrrmon.(Section 7031.5.Bminamiad Professions Cade:Any citymeasom, TEMP.METER OR POLE INST,
which requires a pmmit to consumer,alter,improve,demolish,or r'7 any sweture
CnQ� Pno(mirissuan ,Wsorequim Neapplicatformchpc clofilea signMsmtement POWER DEVICES
,x<0that he is licensed Formant to the Provision,ftha Connector's License Law(Chapter SWIMMING POOL ELECTRIC
9 thin he ar.ociiNSrafors 700))ofbasis
Sof the Business and Professions Cone) VALUATIONS
or that he ix<x<mpuhcrefrom and the bazix for she alleged esemprimn.Any violation of ((// lTIONN cjrww
�ZQ 5¢tion 70313 by any applicant forapermit subjanthe aPPlicannoacivil penalty of ETS-SWITCHES-FIXTURES
not are than five hundred dollars($51X), I.
NEW RESIDENTIAL ELEM S .ET.
o ❑ Lasawrk.a Nepmpcny.many intendceswithwageaasthei(ec.comp emanon, Q STORIES TYPE CONSTRUCTION
y3ep will dothewons and the he ContractoHmadedm offer ed fs not apply
t7044,Business
and Professions wh ons Codedsor i The Contractor's License Lew rices not apply lf an owner of
owns Ywbaos,Novi impravesthereon,amwhorreswchwok hinrelfser through his
employeesilding orimprsuchimpis sold msare nmerndcomplemd the owner- OCC.GROUP RFS.UNITS
however.will
building burden
of pment is sold within me year of completion,the owner- T
M1uilJer will have the hurJen of Proving that he did nm hoild or improve for purpose of
In
Lasownerofthe progeny,emexclusivelycontrectingwithlirenu contractomw QTY. PLUMBING PERMIT FEE F100D ZONE ApN
c most the pmjm(Sec.7 H .Business and Professions Code:)The Contractors
Lic Law does not apply loan ownernfpropeny who builds or improves thereon,and PERMIT ISSUANCE
whoconmsforsuahprojecrwiNacrnramor(Alicensedpunu itothe Contractors ALTER (EA)
License Law. FEE SUMMARY
❑ 1 am exempt undei Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICUTSIDh I EES
OwnerSANITARY YN
Doe DRAINS-FLOOR, A,CON RECHIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Ihcrehyafli(m NatJ have ncaificmc of conunur sell-ire.....a cenifcom of FlXTURES-PER•'fRAP REC[IPI'#
Workers Compensation Insurance ora certified copy Ncreof(Sec.3800,Lob C.)which r PARK FEE Y N
covars all employee's under permit GAS-EAOSYSTEM-IINC.4 ,ETS RECEIPT#
Policy# BUILDING DIVISION FEES
0 Coy G��EA.SYSTEM-
❑ CaifieJ copy is hereby famished. PLANCHECK FEE o
❑ Cenifed copy is filed with the city inspection division GREAS ND ASTE INE GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFA � SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is forma,hundred dollars($100) SE ER- ARY- TORM .200FT. ENERGY FEE
,itI.sa)
Iccnify that in Nc perfmnrtmce of Nc work for which thispernit isissued,lxhall WA HEA W/VE1 /ELECR
m employ any person in my moaner m az to become subject to the Wmrken' PAID
z ApplicantCompensation LawsmCelifomia. Data
WATERYSTEM/IREATING
Dole Receipt#
z C) NOTICE TO APPLICANT:IL after making this CenlEcate of Exemgion.you should NEW RES INITIAL PLM. SQ.FT. TOTAL:
become subject m the Walker's Compensation provisions ofrhe Labor Code,you most
forthwith comply with such provisions or this pemtitxhall Bedeemedrevoked.
_ BUILDING FEE ^,r
LW Q CONSTRUCTION LENDING AGENCY SEISMIC ME
a z Ihereby affirm that hen is a construction leading agency for the performance of
U O the walk for which this pemiit is issued(Sec.3097,Civ,C.) TOTAL: ELECTRIC FEE
[..does Nate
00 U Landers Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I ceniy that I have read this applimnion and state that the above information is
acorrectl agree m comply with all city and county ordmones and onto laws relating to PERMIT ISSUANCE MECHANICAL FEE
F-' V) building construction.and hereby nationu mp(esenativcs of Nis city merearmpon the
U z above-mentioned progeny for inspection purposes, LTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agfec lam',indemnify and keep harmless the City of Cupertino against
Iia iltries,judgments,coats and expenses which may in my way accme against said City AIR HANDLING UNIT(TO 10,000 CFM)
onsequenca of the granting of this .it.
m\ /2 AIR HANDLING UNIT(OVF:R 10,OW CFM)
Sighalme of ApplicanVCionic, a EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEAPING UNIT(TO 100.001)BTU) Dat. Receipt#
Will the applicant or future building resonant store or handle hazardous material
as refused by the Cupertino Municipal Code,Chapter 9.12,and the Health ad Safety HEATING UNIT(OVER 100,000 BTU) TOTAL
Cade.Section 25532(a)'I
❑Yes 0 N VENTILATION FAN(SINGLE RESID)
BOILER-COMP(31IP OR 100,000 BTU) 11SSU{1N;E DATE
Will Ncepplicam or future FuildingoccuPam use eyuipmemordevices whichemir g ; D
h,anidous air cnnmminunts av defined by the Bay Arca Air Quality Management B
OILER
Dixrri.r'1 MAY 17
❑Yes ❑No .JAs
L
ve road the hazardous matenals requirements under Chapter 6.95 of the �' 9�
Ilenhh&Safey Coda Sca'abc 25505,i t 33 and 25514. 1 undersand Net s�7
ding does nut cartoon have a a om.that it is my msrym,ibiliry m amityNeUhGUrrof Nc royuirrntents which mu,t Ise met prior m issuance of.Cenificaa oy.
awboraed agent Date
ED BY: