26626 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO ..,Lu
,-ELL RICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMH NG-MECHANICAL 26626 Q n Q
BUILDING PROJECT IDENTIFICATION Lo Gv
Bl11LDING SANITARY NO. APPLICATION SUBMITTAL.DATE
UNIT. LOT'0
RG S�O�D D" �r
OWNERS NAME: PHONE: CONTRA 'OR'S NAME: LIC NO:
7/O NIC CONTROLp
rD /aN�Z rLuirl id �J(6(o
ARCIIITIiCTMNGINEF.R: LIC NO: ADDRESS: ❑
'ONTAC' PHONE:
QTY. ELECFRIC PERMIT IEE BI111.DING PCRMIT INFO
BLDG ELECT PLUMB MECII
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
meez Ihembyitiman ral am licensed underprovisions of Chiscr9 gorttmamingwith JOB DF CRIPT'TON
�00 Section 1000)of Division 3 of the Business and Professions Cade,and my license is In PANELS
t�w mu farce ata areas
QZy, License Class �-3�i deice. �a UP T02(p AMPS
y6y Date _Contractor-�e'!1� 201- RM AMPS 1
Z FO NZL, ARC[I ITECTS DECLARATION OVER I"AMPS SQ.FT.FLOOR AREA S/SQ.1'f.
OZ-0 I understood my plans shall be used as public mends.
y C J SIGNS ELECTRICAL
�y J hittnsW Professional
p4 TG6
OWNER-BUILDER D the Commodes
SPECIALCIRCUIT/MISC.
WOyCJ I hereby affirm that I am exempt from the Conuactora License Lew for the
W,b Y.ti following reason.(Section 11131.5,Business and Professions Code:Any city ter county TEMP.METER OR)'OLE)NST.
tuJ which requires a permit m construct,niter,improve,demolish,or repair any mra mere
}� primmils issuance.also¢quims the applicant for such Permit to file a signed statement POWER DEVICES
qC
<C) had he is BLenmd pursuanuo the provisiom.(the Contractors License Law(Chapter
i Ooff 9(commencing with Section 1000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
non or that he is exempt therefrom and the basis for alleged exemption.Any violation of OUILCTS-SWIt'CIIES-PI%TI1RE5
} Section 1031.5 by any applicant for o permit subjects the applicant m u civil penalty of
Gnot mI,mown0afthepre rsy,mmye00).
❑ Lusotuner.(thepropeny,mmyempdoyeeawithwegesusrheirrolecompensation. NEW RESIDENTIAL GLECTR in, .Ff. gTOR113 TYPE CONSTRUCTION
i willdothe work,andthe stmcturnaboot intended reoffered forwle(Sm.1044,Business
add professions Code:The Contractors License Law does and apply to an owner of
properly who mild,m improveatheaen,and who dues such work himself.,through his 1
ownemplaym,.,ovIf, OCC.GROUP RFS.UNITS
however,the huildingor imprnvement is sold within one yearofcompletion,the owner- TOTAL:
halide,will hove the burden of preying that he did not build.,improve for purpose of
side.).
❑ 1,asmwner ofue propeny,an exclusively oncoming with licensed contactors to QTY. PLUMBING PERMIT FEE RooD_ZONE "N
constrict the project(Sm.11144,Business and Professions Code:)The Coatrmtoh p[RMI'T ISSUANCE,
License Li w does not apply loan ownerofproperty,whobuidds or impmves thereon,and
whocono-ams livsuchpmjeclswilhacomramor(s)llttnsedpursuant tothe Connncom''x
License U., ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C ferthin reason BACK ROW PROTECT.DEVICE
SANITARY YN
Owner Data RECEIPT p
DRAINS-FLUOR,ROOF,AREA,GOND.
WORKMAN COMPENSATION DECLARATION SCIIpOLTAX YN
❑-1 hereby from that 1 have n cer ific tte clement to sel6matim.or a coal Cmof c RECF.IFI'p
FIXTURES-PER TRAP
covenal C.mpeuses nder hiscarrecesifiW copy thereof(Sm.38W,Lab CJ which PARK TLE Y N
covers all employees under his pcnnil RECEIPT.
GAS-FA.SYSTEM-1 INC.4 OUTLETS Policy. BUILDING DIVISION FEES
Company GAS-EA.SYSTEM.OVER 4 TEA) PLANCHECK FEE
❑ Cerifed copy is hereby furnished.
❑ Conlin.]copy is filed with the city inspection dicisi.t. GREASFgNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF HXEMnION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
phis semionneednot be completed ifthe permit is intent,hundreldollars(IRS) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
at less.)
I Cert ify that in the performance of the work for which this permit is issued,I shall WATER HEATER W/VENT/ELF.CR
not employ any person in any manner
the Workers' PAID
CompematnalrWATER SYSTEMnRPATING
O z Applicant j
Data Rcecipt p
z 0 NOTICE TO APPLICANT:TLaBeT makingthis Comficate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
�+ . becomesubject subjeco the Workers Compensation provisions of the labor Coda,you must
� , forhw ith anmply with such provisions or this permit shall he deemed revoked. BUNAING FEE
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
z
C, 1 hemhy affirm that them is a construction lending agency for the performance of
L) the work for which this permit is issued(Sec.3091,Civ.C.) ELECTRIC FEE
Lender's Name O
0 U LenAddress QTY. MECIIANICALPFRMIT FEE PLUMBINGFEL'
wders I certify that 1 have read this application and state that the above information is MECHANICAL FBI,
cnomel.lugrce mcomply with oil city and county mdinences and state laws relating 1. PERMIT ISSUANCE.
� buildingeonstrumion,and hereby authoaze mprtsentativesefthiacity toenter upon the CONSTRUCTIONTAX
V z above-mentioned Property for inspection purposes. ALTER OR ADD TO MECH.
(We)some to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue againssaid City AIR HANDLING UNIT ITT 10,"CFM)
imcon'eue the t ooft 's ib / /y�,f AIR HANDLING UNIT(OVER IO,OIq CFM)
Signature of Applic t/Cemmctor /// 'Date EXHAUST HOOD OVMUCiy PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IM."BTU) Date Receipt.
Will the applicant or future building occupont sore or handle hounrdous material HF.AT'ING UNIT(OVER 100,00],OTU) AL:
ss defined by the Cupertino Municipal Code,Chapter 9.12,end the Health and Safety
pal
Code,Section 15532pol VENTILATION PAN(SINGLE RMID)
❑Yes 'aNo pli
p1t�n
Will the spplicantorfumre buildingmcunion usemuintrom mdevicm whichemit TOILER-COME DIIP OR 100,000 BTU) /f�T,SS6�A'fN FJ�DATE
�hazamli? air contuminunla as defined by the Bay Area Air Qualify Management BOILER-COMP(OVHR IWp00 BTU) JU1 2 1.
' Diso-in'! ❑Yes n ®(�
NEW RESIDENTIAL MECII. SQ.FT. 1994
Cl! uurrHu
I have rtaJ the hazardous materials requirements under Chapter 6.95 of the r Ur
if the wilding does
Safety endy have ons ant,than
it is y responsind 25534,bility
Tun to
thus ry
if the building Anes not currently have a tenant,thus it is my respnmibility to notify the
trecupom of the requirements wpnth;=issuance ur tyyissuance of Certi r ate of
Owner or nuffrourized aged,
L!g Dam TOTAL: ISSUED BY:
OFFICE