26449 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF:RTINO nD¢DfNc-ec A, PERMIT NO,
APPLICATION/PERMIT PLUMBING-MECHANICAL 26449
BUILDING DIVISION BUILDING PROJECT'IDENTIFICATION
,DIN,�A((�CDIINESS: SANH'ARY NO., APPLICATION SUBMITTAL DATE-
CJ I era- UN[f# LOT# \a
O NL S N li: PHONE: CONT'RACTOR'S NAME: LIC NO: V C
NIC- CONTROL#
�.ARC ITBC GINEF - LIC NO: A R[.58: ❑
CO "ACI': PHONE: • " C
r BUILDING PERMIT INFO
QT V. ! ',--ELECFRIC PERMIT FIiF.
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE 0 El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOBD IPTON
mwz I hereby affirm that l am licensed underprovisi.nnofChepter9(eommerecingwith
P400 Section 7000)of Division 3 of the Business and Professions Cade,and my lice..is to PANELS
y'y�yl� full force and effect. UP TO 200 AMPS
4y6 a Date Class Convector 201- -
8- H III00 AMPS
zOyz ARCIIIneto EM'S UECLARATION OVER I(#NIAMPS SQ.17.FLOOR AREA $/SQ.PT.
Oz_,p Iu Ito Plan.+sM uxcJu ublic recoNs.
W SIGNS ELECTRICAL
6� ccnseAP s new -
L C, a ss 06 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
O ter,U I her off.that 1 am exempt from the C.Corac ors Licenu Law for the - ,
W 3 a Ha following remnn.(Section 7831.5,Hamitic.and Professions Code:Any city or county TEMP,METER OR POLE INST.
,O.] which reymires a permit to construct,altar,improve,demolish,m neper any swaure
tized} prior to its issuance,also requires the applicant for such permit to rile a aignedsutennom POWER DEVICES
C A O that he is licensed pursuenno the provisions of the Connectnr's License Law(Chapter .
µ SWIMMING POOL ELECTRIC
Xan 9(cpmmeis ememith Section RMgnof Division 3.f the Busine.pti.PrMyvi.Cade) VALUATION
I —,m prthe, 7031. by
artyrefrom end the ishma(onhe allcgedexcmpti he civil alta of OUTLETS-SWITCHES-FIXTURES
FZa Section ID31.5ve anydreddnnl forapermit subjaBthe applicantmecivil malty of
ASO not more,than Live hundred J.Ilars($Sep). NEW RESIUFNTIAL ELECfR S .PT.
aE�pro ❑, I..ownernfthcprnperty,ormyemploymswithwaga.thcirwtcc mp don. Q STORIES TYPECONSTRUCTION
i3. will do the work,endthettowwreisnat intended proffered tarsale(Sa.7W.B.inas
and Professions Cade:The C.ntrwmrs License Law does not apply to an owner,of
property who huilds orimpown thereon,and whodomes such work
hind
or through his
own employees,provided dol,ach improvememsamnot mucndedmpfferedformle.If, OCC,GROUP RES.UNITS
however,the building or improvement is sold withinoneyear.(cumpledon,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,ux ownerofth.propery,umexdusively commcting withlimnud mntreaors to QTY. PLUMBING PERMIT PEE MOOD ZONE - APN
construct the project(Sec.7804,Business and Pfafes,icas Code:)The Convector's PERMIT ISSUANCE
License Law dans not apply to an ownerof pmpeny whobuilds orimpewce thereon,and
who Comnu
efor such projects with acontmemr(s)licensed persuannothe Contractors AL FA
(FR-DRAIN&VENT-WATER
Limn,.Lew. U ) FEE SUMMARY
❑ 1 am exempt under Sec. - ,B&PC for this mown BACK 19.OW PROTECT.DEVICE OUT SIDE FEES
SANITARY YN
Owner Date •RECEIPT# -
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ Thereby affirm that have acenilicme of cnnsen¢o self-insure,macenifice¢of 11 FIURES-PERT11AP RECEIPI'p
XT
Workere Compensation Insurance or a certified copy thereof(Sce.3800,Lab C.)which l PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM. INC.4 OUTLETS RECEIPTp
Policy# BUILDING DIVISIO FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ 1 �FA'CF�N 'T .W IIfFT�RCE O GRADING FEE
CERTIFICATE.OF EXEMPTION FROM WORXERS' , � GREASGTRAPs s' ""' T I SOILS FEE
COMPENSATION INSURANCE '^
(This section need nm be completed ifthe permit is forone hundreddolums($100) PVfi -� ^A - w0 .300FR. ��`S ENERGY IEE
or las.)
Icenify that in Ne perfotmanm o(Ne work for which Nis permitis issud,Ishall WAT IIEATT .L
not employ any person in any manner am as m become subject tp the Workers' PAID
Compensationlawsof C.1hooia. Dote WATL'R SYSTi!FIl}1D7R1fIR� Date Receipt#
O z Applicant
Z 0 NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
!—a Vj became subject to the Workers Compensatimt Provisions of Ne Labor Code,you must
foMwith comply with such provixions en this permit shallh deemed revoked. BUILDING FEE
O
CONSTRUCTION LENDING AGENCY. SEISMIC FEE
1 hereby from that there is a Construction lending agency fm tperformance
he of
the wank fist which this permit ix issued(Sec.309],Civ.C.) ELECTRIC IEE
L2, .-a LenJer'e Name r PLUMBING FEE U Leadcr'a Address, QT'Ya MLCIIANICALPERMIT FEE
1 certify the,I have read thin application and stem Nm fie above information ie
>. W cored.Iagree mcomply with all city hired county ordinances and state laws minting to MSCI IANICAL FEEPERMIT ISSUANCE '
�-' Ln building Construction,and hereby authorize representatives ofthiscity to enter upon the
'V K above-mentioned property,for inspection purprean. ALTER OR ADD TO MECH. CONST RUCTION TAX
(We)agree on save,indemnify and krep hermlesa the City of Cupertino against
liabilities,judgmems,costs andexpensa which may inanyway arueag nstsvid City AIR II ABOUND UNIT(TO I0,"CFM)
in conseq a ofthe granting of pe
AIR HANDLING UNIT(OVER 10,000 CFMI
nawreo paean oat to EXHAUST HOOD(W/DUCIT
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IM."BTU) Date Receipt#
Will the applicant or future building...pant smote of handle hazardous material HEATING UNIT(OVER 1 W,1100 BTU) TOTAL:
as defined by the Caperton.Municipal Code,Chapter 9.12,and te hHealth and Safe,,
Code,Section 25532(u)J VENTILATION FAN(SINGLE RFSID)
❑Yes ❑Np
Will the applicum nrfuwrc M1uildingmcupant use equipmem ordevices whichemit
BOILER-COMPONPOR 100,000 BTU) I S +N BDAT
h..w.nm at, motheamos is an defined by the Bey Area Ar Quality MMgCMMt BOILER-COMP(OVER 100,000 BTU) U� 1 ,gQ4
DistricB v
❑9n ❑No NIJW NI351DIiM'IAL MECH. SQ.PT. � y
1 neve read the haeavdnus mumriulx reyuircmeme ander Chap¢.6.95 pr nm V� VUrClyllly
Culifowia lfenith&Safety Code,Sections25505,25533 and 25534. IunderswnJ tlmt U
if the building dne,not currcn8y have v tenant,that it is my responsibility to notify the
wcupmtt loll the requirements which must he met prior to issuance of a Cenifcate of -
Panpunvy.
Owner or authorized agent Date TOTAL: ISSUIiD BV:�
OFFICE