26433 (2) 1
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Bfm.-Dwr.-ELez,RPl AI. PERMITNO.
APPLICATIONIPERMIT PLUMBING-MECIIAN'ICAI. 26433
BUILDING ADDRESS:
BUILDING PROJECT IDENTIFICATION
ItU1LU1NGAWRISS: SANITARY NO. APPLICATION SUNMTIT'AI.UATE
' "rX hOTp r'
t NE: COMROACfO 'S NAME: LIC NO:
N/C CONTROLp
NNTACT:
CIITH '/ENGINEER: LIC NO: ADDRESS: ❑
PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
'Y BLDG ELECT LUMB MliCll
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRI ION
nwz Iherehy ofirmhot]an,lleensedunderpmvisions of Chapter 9(commencing with
ul OO Section t,and e f Division 3 of the Business and Professions Cede,and my license is in PANELS
FCU full l'urce anJeflbn" '1/r_r/�•�a}_1 IAV"�
<,, License Class Lie.# UP T0200 AMPS
m=M Date Convenor 201-1000 AMPS SQ.IR.FLOOR AREA SISQ.FT.
'G OvNiz ARCHITECTS DECLARATION OVER 1000AMPS
O Z o,O I understand my plans sM1all be used as public records.
I--,y F w SIGNS ELECTRICAL
Q Licensee Profcssiuml
ceQ OWNER-BUILDER DECLARATION SPECIALCIRCUMIMISC.
KOyU I hereby uffimt that 1 am exempt from the Contractors License Law for the
W1 :a o, following Caxn.(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
I_" O5 which requires a permit m Contacted.aIle,improve,demolish,or repair any anYcture
Q� to its issuance,also Nee applicant forsuch tin file esi ed statement POWER DEVICES
prior quires Pr perms gn
W CO that Ke ie licensed puauanuu the provisions of the Contreclor'e License Lvw(@opts, SWIMMING POOL ELECTRIC L
9(commencing with Section 700b of Division 3 of Ne Business aM PCfessiom Code) .. i I VALUATION
Wim uIn.,he isexcmptlherefrnmand the basis for the alleged exemption.Any violation Of
F.Z, Section 7031.5 by any applicant for a Permit subjats Ne applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES i a �- r L
p
p,,,1,1m Ilvc hundrW Aollars($500)Kp� efoDM1epCpeNEWRFSIDENTIALELECTR 5 .FT. RIES TYPECONSTRUCIION
ywork,and the strucmrc is not intended or offered far sale(Sec.7194.Businesssions Cale:The Contractors License law does nut apply to an owner of
ho builds nr Improves thmcon,enJ undoes such work M1imsdf or chmugh his
cmpbyceaprovidedthatsuchimpmve6 un doe ss intendedoonselfcdfmsale.IL OCC.GROUP RES.UNI IS
however.the building or Improvement is sold within one yearofcompletion,theowner. TOTAL:
builder will have the burden of preving that he did not build or improve for purpose of
sale.). QTY. PLUMBING PERMIT FEE
❑ I,avnwnerefche pCpenY.em exdusivelymnuaning with licenuA contnaors co FLOOD LONE APN
,roue the project(Sec.7044,Bnsiness and Professions Code.)The Contractor's /
Licenxlawdncsnotapplytoanownerofpropertywhebuildsmimproves Nereon,end PERMIT ISSUANCE
who contracts for such projects with a conmemr(s)licensed pursuant to the Conttmtor's ALTER-DRAIN&VENT-WATER HIz%) FEE SUMMARY
Lice u Isw.
❑
License,
am exempt under Sec ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTS ID-FEE
)wnc, Dow SANITARY Y N
DRAINS-FLOOR,ROOF,AREA,COND. RECEIPTM
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Iherebmu ti nlmuveaddnil ifs rnUffiersf( nsmm,o.UbC.)c hich FIXTURES-PER TRAP RECEII'1'p
Wmkera Cemputsetionlmurance oreccnificd wpy NCrwf(Sec.Jg00,LabCJ which PARK FEE YN
II employee's mold,this Permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT p
I cy X BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER4(EA) PLANCHECK FEE
❑ Certified copy is hereby furrdshed.
❑ Cenllied copy is fled with the city inspection division. GREASF/INDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS HE
COMPENSATION INSURANCE
(This section need not he completed file permit is forone hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or lam.)
I Cerify that in the pe d..nes,of the work for which this permit is issued,l shall WATER HEATER W7VENT/ELECTR
nm employ any person in any manner C as to become subject to the Workers PAID
COmpcnsaeon Lawxef Celifomia. Date WATER SYSTEM/TREATING Data Receipt
� Z Applicant
0 NOTICE TO APPLICANT:If,after making this Cenificamof Exemptlon.yeu should NEW RESIDENTIAL PLMB. SQ.FT. TO'T'AL:
(n became subject to Ne Workers Compensation provisions of the labor Code.you must
� ? fnre nhwithcamply with such pmvisiuor his permit shall he deemd Cooked. BUILDING FEE
0. Q CONSTRUCTION LENDING AGENCY SEISMIC HE
1 hereby affirm Nat there is a construction lending agency for the periortnance of
� 'Z the work for which this pe,mit is issued(Sec.3(19],Civ.CJ A f:LGCfRIC FEE
U Lender's Name
u" F lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING ITE
O U I certify that 1 have read this application and since that the,above information is MECHANICAL FEE
>� W coned. I agree to comply with all city and county ordinantts and state laws relating to PERMIT ISSUANCE
(—' N buildingconstrvetion,and hereby authorize representative ofthis city mentor upon the CONSTRUCTION TAX
U Z above-mentioned progeny for inspection purposes. ALTERORADDTOMECN.
(We)eg.es save,indemnify acrd keep Hess the City of Cupertino against
IiuhilitiexJudgirlp.c.slion ..pens+whi I wayaccrueagainstsai icy AIR HANDLING UNIT(TO I0,000 CFM)
in concept o he grat ri f Ni
/ AIR HANDLING UNIT(OVER IO.fIOD CFMI
S' nanve of APPlica Gmuuccer Date EXHAUST DOUG W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE. HEATING UNIT(TO 100,0011 BTU) Dam Receipt#
Will the Vdicaut or future building Occupant store or handle mramous material
as defined by l he Cupenine Municipal Cove,Chepcef 9.12,and the Health mad Safety HEATING UNIT(OVER 100.000 BTU) I^
Cale.Section 25532(a)7
11 Yes ❑No VENTILATION FAN(SINGLI3 RI3ID)
�I Will theepPlicanmrfuwre building oecupumuse equipmemordevices whichemit
BOILER-COMP(3HP OR[00,000 BTU) ISSUANCE bATE
hvndous air contaminants a defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,1100 BTO) PDismict7
❑Ye ❑No NEW RESIDENTIAL MECH.—SQ,FT.
1 have read the haaadous materials requirements under Chapter 6.95 01the MAY 26 1994
California 1lwlth&Safety Code,Sections 25505,25533 and 25534. 1 understand Nat
if the building does not currently have a tenant,that it is my responsibility to notify the
cc of the requirementsrequirementswhich must be met prior to issuance of a Certificate fI of � Y Ur;`\\
(XcuponupancY. VIkV�/�/IIi01��//J]7VI h/
Owner er authodecd agent Date TOTAL: ISSUED BY:
OFFICE