26179 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO r' ,.. A. PERMD'NO,
APPLICATION/PERMIT PLUSIRING-MECHANICAL 26179 CTI �[J
BUILDING DIVISION BUILDING PROJECTIDENTIFHJA'IOry o 1 J
R . INGADDRFSS: ��a rr SANITARY NO. APPLICATIONSUBMITTALDATE
10 ' S 0_f ryTC(,. UNIi'p LOT#
O ERS N ME: PHONE: C ORS NAME �/� LIC NO:
I e>t r11 \V . NIC CONTROL#
ARCHITEECTI-NGINEER: /` LIC NO: KESS: •Iii ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
P CH
PERMIT
PERMIT ISSUANCE 12
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
pyZ I hereby affirm that l am licensed underpmvisionsof Chapmr9(commencingwith
�UOO Section e andefDivision 3af the Business and Professions Code,and my license is in PANELS
y�UE full throe and ellen.
F-UL,, License Class Li,.IT UP TO 200 AMPS
to<vo Uate Cony«tm 201-1000 AMPS
F' zARCHITECTS DECLARATION
%ON^ OVER 1000 AMPS sx Q.ET.FLOOR ARG S/SQ.FT.
OZ-0 1 understand my plans shall be used as public records. \`9l
F rn SIGNS ELECTRICAL `' ^'
Q Yj Licensed Professional ^ ZZ�yr�Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MIS 11 .� RX O y F 1 hereby affirm than I am exempt from the Com ustors License taw for the J ��
w a rn following reason.(Section 7031.5.Business and Professions Code:Any city or cowry TEMP.METER OR POIE W
I_LL�; which motairea a permit to conwmn,ahw,improve,demolish,or repair any spanure
'WD 7 prior to its issuance.also requires the applicant for such permitto file a signed statement POWER DEVICES
,W<0 that he is licensed pursuant to the Provisions of the Commebts License Law(Chepmr
d 2'L 9(commencing with Section 2000)of Division 3 ofthe Business and Pmfecsions Codg WIMM WG POOL ELECTRIC e) VALUATION
ty,_y
Or she,M17031.5 by any efmmnt for
basPermfomheascgedenempst to civil Penalty
of OUTLETS-SWITCHES-FIXTURES ��• � wW
F Z G Section a is 1.5 by any applicant for u permit r the all the applicant b n civil penalty of w`l
�Sp t Than Rve hundred dollars($SW). NEW RESIpENT1AL ELECIR _SQ.FT.
CFo I,azowneroHM1epropeny,ormyemploy«switM1 wages aztheirsolecompensaJon, STORIES TYPE CONSTRUCTION
will he work,anJ the alrunurc is not inbndeJ oruffered for Bale(SecA046,Business
and Pro soon'Cade:The COntmnors Liwrse law does not apply to an owner of
factory whohuildsorimproves thereon,undwhodoessuch work hindodfor Juough his
wnempluyees,pravidW that such improvemenrsarenotimendcdorofferW forsale.If, OCC.GROUP RES.UNTTS
however,the building or improvement is sold within one yew of completion,the wavier.
holder will have the burden of proving that he did not build or improve for purpose Of I
❑ asownerofthe rject(Sropcny,am Business add
nvaniions Codd:)
contractors to QTY' PLUMBING PERMIT FEE FLOOD ZONE ppN
omww the oesma(Sec.to an
Bus and Professions Code:)The Connector's
LicenmLow doesnmapply bunowncormartperywhosed pumimtioduchereon,and PERMIT ISSUANCE
whew Law. rsuchprojecu wi0acontiwbKs)IicenuN pwauanlb Ne Cono-acbra ALTER
Llcenu Law. DRAIN&VENT-WATER(FA) FEE SUMMARY
❑ 1 am exempt under Sec. B&PC for this reason BACK FLOW OTECT.DEVICE OUTSIDE FEF_S
PR
Owner Dam SANITARY YN
DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Iherebyaffoodon I have a certificate ofronsenno Self-imure,or a cerdficam of FIXTURES-PER TRAP RECEIPT ee
Workers Compensation Insurance el acenified only theawf(Sec.3800.LabCJ which PARK FEE YresorN_
rs all employee's made ,his patron. GAS-EA.SYSTEM-]INC.4 OUTLETS RECEIPT'#
Policy# BUILDING DIVISION IT-ES
Company
Certified copy is hobby famished. GAS-EA.SYSTEM-OVER4 TEAT PLANCHECK FEE
❑ C
❑ Certified copy is filed with the city inspection division. GRG$FJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thisdeion need not be completed ifthe permit is for one hundred dollars(SI00) SEWER-SANITARY-STORM EA.200FT. ENERGY FEF,
or less)
I certify that in the performance ofthe work for which Nis permit is issued,l shall WATER HEATER W/VENT/ELECIR
m employ any person in any manner so as or become subject to the Work.' PAID
Coutherwtionlawsof Califomia. Dem WATER SYSTENIt REATTNG
Applicant Dane Receipt If
z O NOTICE TO APPLICANT:If,after making this Cmifiw¢ofEmmpion,you should NEW RESIDENTIAL PLMB. SQ.PT. TOTAL:
(•-' V) become subject m the Workers Compensation Provisions mi Labor Code,you must
7 forthwith comply with such Provisions or this permit shall be deemed revoked. BUILDING FEE
per„ Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z) z f hereby affirm that them is a construction lending agency for the performance of
U O the weak fm which this permit is issued(Sm.309),Civ.C.) �- ELECTRIC FEE ��
Lvader's Name
0 V Lenders Address QTY. MEC14ANICAL PERMIT FEE PLUMBING FEE ��
I sanity that I have read this application and arm that the above informed.is
coned. lagree m comply with all city and county ordinances and state relating do PERMITISSUANCH MECHANICAL FEE
_ buildiagconswction,mdhcmbyaufodumPr nmdves ofthiscit"omtcrupon Ne
U Z above-mentioned mrany for insp«rion purposes. SHPATING
D T!IW,�
!PAID
TRUCTIONTAX
(We)agree to save.indemnify and keep harmless The City of Cupeaino against
IiabiI IiesJud cr tsend cs which may in any way we
said City G U0 CFM)
i con 4 ce he granting of s5pcnnit.
ce- 2 G UNIT ,000 CFM)
Signature of Applicam/Comfa tar a OD
HAZARDOUS MATERIALS DISCLOSURE T(T ) DaneWill the applicant or future building occupant store or handle hazwdous material
ds defined by she Calmar,Municipal Cade,Chapter 9.12,and Jae Health and Safety T(OTU) AI
Code,Section 25532(a)7 11
13 Y. 11 NO VENTILATION FAN(SING LE RESLD)
or BOILER-COMP(3111'OR 1 W,1100 BTU) ISSUANCE DATE
Will air contaminants
s building by he Bay A At,Quality eadju emit PAID O
hastort? air com:uninana us ddineJ by the Bay Arw Air Quality Managemcm BOILER-COMP(OVER 1W,OW BTU) r kai
DixWa^
❑Yes ❑No NEW RESIDENTIAL MECH. SQ,fT. MAR OR
Llic.hh
rad the hazardous materials requiremenu undo,Chapter 6.95 of the F/ 1994
eahh&Safety CWe,Sections 25505,25533 and 25534. 1 undw,ea dthatrg dos not cumendy haveatenant.Nat it is my responsibility bnotify the VUr the mqumarems which must be met prier to issuance ofa Cenifeate ofJ�hodzed agent pate
TOTAL ISSUED BY:
OFFICE—