26201 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
MY OFCUPERTINOBUMM.�c-ELECTRICAT PERMITND' 1
APPLICATION/PERMIT PLUMBING-MECHANICAL Z 6 Z O 1
BUILDING DIVISION RUILDING PROJRCY'IDRNTIF'IC.AIDON
BUILDING ADDRESS: SANITARY NO. I APPLICATION SUBMITTAL� DATE
UNIT LOT )
OWNERS NAME: PHONE: CONTRACTOR'S NAME: LIC NO: NIC CONTROL 000
ZSS"
ARCHITECTRNGINEER: LIC NO: AD KESS: ❑
ON3'ACI': PHONE: BUILDING PERMIT INTO
QTY. ELECTRIC PERMIT FEE
G t — SLIG ELECT PLUMB MUCHPERMIT ISSUANCE
1:1 El 11
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL YYY
mwz Iherchyaffnmthm l an lismeadunderpeuvisions ofaripter9(commencing with LOB DESCRIPTION
sU00 Seenon 9000)of Division 3 ofthe Business and Professions Code,and my license is in PANELS
yew— full fora and t. t�A.a �}'�" l�llQ _
ay� License O4 Lic.p T�,Z 660ogg2 UPT0200AMPS `�J L1v`j
y¢y Date cnrnraern.T3�?� 301-1000 AMPS
FyZ ss ARCHITECTS DECLARATION
OVER I000ZOrn- 1 understand rstanJ my plans shall be used ns public rtcoNa. AMPS
OY—O SIGNS ELECTRICAL ® FL U T
E r1
�1
Licensed Professional
gi p.a'6 OWNER-BUILDER DECLARATION SPECIAL CIRCUUMISC.
aOc. I hereby affirm that 1 am exempt hem thu Contractor's License Law for the
L�a U hdluwing re
c.
903 L5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST. A'fE
F1'0a which requires a permit to construct,alter,improve.demolish,or repair tiny awnare
'W}:2 prinrm its is,awa,ids.requires thenpplicant for such pmmiuo file nsgned smtemmt POWER DEVICES
,KaC that he is licensed pursuant to the provisions mine Contractors License Law(Chapter
ii�C SWIMMING POOL ELECTRIC
Xaa 9(canuneis(commencing Section it he basis for 3ef the Business and.Anyvmm Cede) I— VALI
—m onhathcf31.5by themfromandthc basfsforbje is thedpplica exemption. ivilpamfonof OIITLETg-SWITCHES-FIXTURES
FZ_} Section than by anydred dantfmapermit subjects the amplicannoacivil penalty of
net mom than live hundred dollars(ympl
�Sp NEW RFSIDEN'r1AL ELECIR _SQ.FT. STORIES TYPE CONSTRUCTION
K F_22 ❑ Lmownerandthesmcrty,ormyempended arrofwegesastilei(See compensation,
a3°= will dmhewonsCaceTheCom isnot'snandese Law ficied
not apply in an Business
and Professions ld—,i TheCommerce'stmasma. nd.be Law does not limply to an owner of
own em wheel.provided
improvesthereon,andwha rmsaochwork hfmreciedthrough his
employees,prnvidN that such improvements rum intended orof(emd for sale.If. OCC GROUP RES.UNITS
however,the building orimproverand is sold within one yearofcompletion,theowner- TOTAL
builder will have the burden of proving that he did not build or improve for purpose of
sale')' PLUMBING PERMIT FEE FLOOD ZONE APN
❑ [.as owner of the property,am exclusively contracting with licensed contractors In QTY.
Lmstrin the pmjcct(See.9844,Business and Professions Code:)The Convector's
icense lawdoes not apply to an ownerofmropeny whobuildsorimprovee therean,and PERMIT ISSUANCE
whouammcts for such projects with romeduactuKs)licensed purauanlothe Comeactor's ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
License law.
❑ 1 oto eaempt under Sec. .B&P C for this reason HACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF.AREA,COND. RECEI a
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ IhemM1y orlon Nalhaveacenificate of consenuo self-insure,meartificam of FIXTURES-PER TRAP RECE p
W kerRCo incromlun losumnceora certified copy thereof(Sec.380).Lab C.)which PARK FEF. Y N
covers aIle I pc t REC lTp
41iF s'3pder fM1fa_ngj3 GAS-EA.SYSTEM-I INC.4 OUTLETS HUR.DI GDI 1 Im S
Policy a V[il'b13 `/
El Cry.STJ]Tfi -N��rd. /r�VeS�AE� GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FHE
❑ Crmfied copy is filed
rV�
a�Ccniticd copy is fled with the city inspution division GREASILINDUSTRI.WASTE INTERCEPTOR GRADING ITE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASE TRAP SOILS FEE
COMPENSATION INSURANCE
CHus section need notbecompleted iftbe permit is for one hundred dollars(EI00) SEWER-SANITARY-STORM EA.3001T. ENERGY E
or less.)
I cenffydim in the perfomana of the work for which this parran is issued,l shall WATER HEATER W/VENT/EL[6TR
nm employ any person in tiny manner an,as to become subject to the Warriors' IFEEPLUMBING D
Cnmpcnmtion Iowa o(Califomin.
Data WATERSYSTEM/DtEATING Date Receipt
O z Applicant
z 0 NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should NEW RESIDENTIAL PLM B. SQ.FT. TOTAL:
(•-' (A became subject to the Workers Compenmtion provisions of the Labor Code,you must
� > forthwith comply with suchpravisiensorthisNmtitshallhedeemedrevoked. LDING PEE
4 (] CONSTRUCTION LENDI NO AGENCY SMIC FEE
Z I hereby affirm that them is a construction lending agency for the performance of TOTALCI'RIC FFIi
U O the work for which this permit is issued(Sec.3099,Civ.C.)
Leaders Name QTY, MECHANICAL PERMIT +e
LcndIi AddressL) I certify thin I have mad this ity addcou and stone Chet the above informatin fs CH CAI.FEE
bonding Iagreto coon. ldh=bylciry and laws a PERMITISSUANCEJZabovenmennmmd propprl heeebspecti npurpses. esofthiscitymentauponthe NSTR ICf10N TAX
U z uhnv(We)tigreamopeny fmfnspec and pee,her ALTER OR ADD TO MECH.
(We)agmc m/Ih� -'m
'ndemnify and kap harmless the City of Cupertino against
liabflities,judgmenand famseswhichmnyinanywayuccruengvnst aid City AIR HANDLING UNIT(T010.000CFM)
in erose c of f Ilii it.
3 AIR HANDLING UNIT(OVER 10,000 CFM)
Slg(tim of Ap icmnCcmmctor c D EXHAUST HOOD(W/DUCI) PAID
1/\ HAZARDOUS MA'FER1ALS DISCLOSURE IIHATINC,UNIT(TO I00,00o If I U) Dalcivet a
W III the.,plica or future building occupant store or handle hazadous material 7 TAI.
HEATING UNIT(OVER 100,000B BTU)
ar ddincd by the Cupcnino Municipal Cadc.Chup¢r 9.13,and the tiwhh and ga100,000 .
Code,Sen fon 25532(a)9 VENTILATION FAN(SINGLE RISID)
❑Yea ❑No
ISSUA E DATE
Will theapplicantorfummbuildingmeupaniusccquipmernordeviceswhichemit BOILER-COMP(3HPOft IOO.OW NTD)
harnrdeus air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100.000 wrU)
•Distals'! a'Y B D
❑Yes 0 N NEW RESIDENTIAL MECH. SQ.FT. p� V
1 have read the hazardous materials 5505,25533 under Chapter erst of the m/�r\ (I
914
California have
a alth read
Code.Secmateria nexpd 3553)snd under harmer 6.95 ofthin an% 9 19'
if the building does not currently have a tenant,that it is my rcsponsibiliry m notify the �7
occupant of the requirements which must he met prior to issuance of u Certificate of Cu Y
O"a"aey, Vr Q UY rl,
Owner or omhoriaed agent Date TOTAL: ISSUED BY: