26591 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY V
CITY OFCUPERTINO �N 'P"�'TRLC PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMB -MECHANICAL
BUILDING PROJECT IDENTIFICATION
2 o 591 J1
BUILDING ADDRESSS:�k/� -r i`/ SANITARY NO. APPLICATION SUBMOTAL DA'M
UNIT# v 'T
OWNERS NAME: PHONE: Cg�+Zrt"CI'OR'S NAME: LIC NO: N/C CONTROL#
7ftNn W)
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
1"1 edit fd ( +fit 0 A15
�i
CONTACT: II USE---,' QTY. ELECTRIC PEBUILDING PERMIT INFO
PERMIT FEE
I sA BL
ELECT
.� P_LOMB ME i
PERMIT ISSUANCE V V
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
pyZ I hereby affirm Lou l an licensed underprovisiom of Chapter 9(commencing wit
P00 Section70(1 Division 3ofthe Business end Profession$S24,and my license is in PANELS
yddu muroreemdeffecl. r7 C — I
FZW License I Lic.87 JJf 7Zi1 UP TO 200 AMPS J� /�„/
y y Dom C
TECT5 DT'S DmECLARATION W EA 11 1 1 201-IOAMPS SQ.FT.FLOOR AR $/SQ.IIT.
ZOyZa ARCIi1OVER 1000 AMPS
OZ-0 I undersand any plans shall be used as public rccards.
J SIGNS ELECTRICAL A
Q� J Licensed Professional f )� X •4Z
LyrK6 OWNER-BUILDER DECLARATION SPECIALCIRCUTDMISC. l$
kO LI I hereby affirm Net 1 ore exempt from the Contractors License Law for the
W 3 LLOya following reason.(Section 7031.5,Business and Professions Cade:Any city orcounsy TEMP.METER OR POU MST. a r _ as/ 'L�
($_ w J which requires a permit to construct,alter,improve,demolish,or repair any structureI✓y0
prior in its issuance,also requires the applicant for such permit to file aligned statement POWER DEVICES
_ p
that he is licensed fursomt to to provisions of to Commences License Law(Chapter
0. e 9(commencing with Section 7000)of Division 3 of the Business and Profeminru Code) SWIMMING POOL ELECTRIC VALUATION
or yes
Section
h7031.5 by any aefmmanfr a Pens(subjects thedesempti n.too ny civil
Penson of OUTLETS-SWITCHES-FIXTURES 1g3
Y Section 7031.5iv any applicantrs$permit subjects the applieummacivil penalty of �T 1,
G not momthanroftherodny,lam(SSW). NEWRESIDENTIALELECIR SQ.FT. r l
❑ 1,usawnuroDheprapeny,nrmyempleyeeswit wegaestheirsolecompereation, STORIES TYPE CONSTRUCTION
a2.0. will do the work.and the stmctureisnot intendedoroffered for We(Sec.]D14.Busiaess
and Professions Code:The Contractors License Law does not apply to an owner of
property who buildsorimprovestereon,and whodoee such work himselfonhroughhC OCC.GROUP RES.UNITS
On
employe buprovided tat ouch impr,and wvs are molintendedmoffered forsage.If,
however,the buildingor improvement is sold within one yearofcompletion.the owner. ' �•1
On ilderwill have the burden of that he did not build or improve for se of OTAL: t
pmvi^6 P purpose
QTY. PLU BING PERMIT FEE
❑ I,u+ownerol'the prnpeny,untuclusively cnnvn<ting with licensed conuactorem I1,00D ZONE APN
construct to project(Sec.7044,Business and Professions Cale:)The Coaoactors
License Lawdoes not apply to imownerofproperty whobuildsa impravestherian,red PERMIT ISSU NCE
whocuntmnsfmauch projects wiNacontratdorbolicensed pumormte Com"oes ALTER- AIN&VPM
License Law. TER(EA) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this mason
BA FLOW PlitonckpriV SANITARY Y N
Owner Data DRAINS-FLOOR.ROOF, ,C RECEIPT
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Thereby nffirm thntihav<ac<nificme ofcortsenuo serf-insum,oreartificem of Fl RES-PER TR RECEIPTof
• Workers'Compemation Insurance cru certified copy theroof(Sec.3900.Lab C.)which PARK FEE Y N
coven all employee's under this PermitGAS- .5 - NC S RECEIPT#
Policy N BUILDING DIVISION FEES
Company GAS-EAS OVER4( ) PLANCHECK FEE ''O ob
❑ CertlEed copy is hereby famished.
❑ Certified copy is filed wit Ne dry inspection division GREASFAUSTIC4ASM INTER EPfOR GRADING FEE �•
CERTIFICATE OF EXEMPHON FROM WORKERS' GREASE TRA SOILS FEE
COMPENSATION INSURANCE
(Tis section nod not becompined ifte Permit is forces,funded dollars($100) SEWER-SANIT Y-STO EA.200FT. ENERGY FEE
or less.)
I certify tat in the performance oftha work for which tis Permit is issued,l shall WATER HEATER W/VENT/ELECTR
nes employ any person in any manner so m to became subject an the Worker% PAID
Compensation Laws of California. Data WATER SYSTEMTRFATING Data Receipt
Applicant
O0 NOTICE TO APPLICANT:If,after matin this Certificate of Exemption.you should NEW RFSIDENTIALPLMB. SQ.FT. T TOTAL:
e pti 1
r > bechwithc reply Ne Worker's Comps or
Permit
tshall thNe Labor revoked.
must
� 7 forthwith comply wit suchprovisiomatis pennitahallhdeemd revoked. BUILDINGFEF. W166 IM
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE lye
z I hereby drum Nn mere iso constructionlending agency for the perfonrwnca.f TOTAL: •'"l ELECTRIC FEE
O the work for which his permit is issued(Sec.3097,Civ.C.) 041 -18
Under'.Name PLUMBING PEE
F Lender's Address QTY. MECHANICAL PERMIT FEE Ll I
O W 1 certify Nat I have mad this application and atatc that flue above information is MECHANICAL FET? �1 D
`y. a
correct.l agree m comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE i e
Zbuilding construction,and hereby authorize representatives of this city to enter upon the CONSTRUC IONTAX
ubovcmetnioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)same to save,indemnify and keep harmless the City of Cupertino against
Iiubili lies,judgments,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,"CFM)
in c eof t<grunting of tlppertnit. AIR HANDLING UNIT(OVER 10,000 CFM)
'f D
Signor r prcaM rroact IData I EXHAUST FOOD PVDUCn PAID
HAZARDO MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Done Receipt#
Willtbe applicant or for..building acupant stow or handle hazardous mmerix]
HEATING UNIT(OVER 100,1X10 BTU) TOTAL:
os defined by the Cupertino Municipal Cede,Chapter 9.12,and the Health and Safety
Cade,Section 25532(a)? VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
Will theappllcant osmate building occupant useequipmentordevices whichemit BOILER-COMP(3HP OR 100,000 BTU)
hazardous ab contaminants as defined by to Bay Area Air Quality Management BOILER-COMP(OVER 100,0!10 BTU)• tvx �1 p
Distinct? '
❑Yes 11 No NEW RESIDENTIALMECH. SQ.IT. OCT T $
I have mad the harmonic.,materials ,, mm under Chapter 5.95 of the 1994
California I Iealth&Safety Code.Sections 25505,25533 cad 25534. 1 understand that �fp
tribe building does not currently have a tenant,that it is my responsibility to notify the �!!
occupant of the requirements which most be met prior to issuance of o Certificate of U!• LvrCJ'I lU/�Iq���
Occupancy. V IT�►1
Owner or authorized agent Dam TOTAL: ISSUED BY:
OFFICE