26685 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO .BIrss .. Z-TRICZL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
26685 6 6 O 5
BUILDING DIVISION - IIUILBING I'RWRC'1'IIHfN"1'IWf;A'TION of
BUILDING ADIlRFS3: '1, /� ���UNITM LOTS SANITARY NO. f1/PPLI fTIO'NSUHMCl/JTTAL DA'1'R
OWN
VP1IH/pQ/y�y/� (� CONT CTOR'S NAME: LIC NO:
�/e e e /� T UI'f C]/ s. I , '(Y{' ajS/� N/C ONTROL
ARCHITECT/ENGINEER: LIC NO: ADDR.. 6-3L1 U Q1 �� ❑
CONTACT: PHONE: t s t""'"v,.� ' 41 E'� I ' " UILDING'PEItMIT�INPO
f�LA �GP
,� E13 RIRMIT�Y
FEE B
BLDQM ELECT PLUMB MF.CH
PERMIT ISSUANCE
LICENSED CONEl El 1:1TRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL ( 10g�DEECRIf El
OtYZ Iherebyaff tat that I licensed underpmn visioof Chapmr9 m
(rnmrncinB withG✓l i✓YIHC-� /UryJ
WOO C Section 7")of Division 3 of the Business and Professions Cade,and my license is in PANELS 1
� E fan rmaa rant arrat:t L a
F,ZaI License Class Lic.p 'jSy UP TO 200AMPS 5
L,<y Dam Contractor e> 201-I WO AMPS
'LOy� ARCIIITECI'S D[CGRe. a OVER 1000 AMPS SQ.FT.FLOOR AREA E/SQ.IT,
FN�Q yp�p{ylat�sy7lpll be uao> .bllc records.
p1 l/� (j.� SIGNS ELECTRICAL
< 7 j Licensed Professional
PjOWNER-BUILDER
70V1 1v/k\
yY.tY< OWNER-BUILD from
DECLARATION Cmum10N SPECIAL CIRCUTT/MISC.
O.V I hereby of(Section
that 1 am exempt!ren the Contractors License Lew for the
wan-rF„ which require permit to comu, t, he,.improve,
demolish.
le:Any city in county TEMP.METER OR POLE INST,
F aJ�; prior
ri rM1 requires a permit to outs t e,alta,improve,h pannitt or mash any statement
f }� pdonn itsissuance,pulsoot to the
tprvishe ionsof theuchpcmtino file a License
La atatemem POWER DEVICES
that nisrsinsedpumction theprovisionsof the Contractors License Lew(Chenter
0.T1oCL ')(commencing with Section 7000)of Oivisinn3of the Business and Profession Centel SWIMMING POOL ELECTRIC �r VALUATION
XW❑rn nnhmheisexempuherefroto and tM1e buxisfor the ollegW exemption.Anyvidetion of OUTLETS-SWITCHES-FIXTURES
b-Za- Section 7031.5 by anyapplicam fore permitaubjects the epplicenttovcivilpenaltyaf
Sry C no,mention five hundred dollen(E$W). NEWRESIDENTIALELECTR _SQ.Pf.
R pw ❑ I,asowncrnUhe property,ormyemploYees with wages astheiraolecompecomma, STORIES TYPE CONSTRUCTION
Y] will do the work,and the struenne isnot intended ormlend fortaleSce.7044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
properywholimidsorimpmves thereon,and schemes such work himselforfirough his
employees,pmvideaUm
that such improveentsara not intendedorofferedfoute.If, OCG GROUP RES.0 TS
however,the MTildingor improvement is sold within one yearo!completion,the owner- TOTAL:
builder will have the burden of proving That he did not build or improve for purpose of
suals.
❑ )I,azowrmrof the prnpeny,amexclmivelycomracting win licenxdcontmctora to QTY:j'�' PLUMBING PERMIT FEE I'LOODZON8 APN
nstruct the project(Sec.7044,Business and Professions Code:)The Contractors
License Lawdoes not apply to an owncrofpropeny,whobuilds orimprovesthereon,and PERMIT ISSUANCE
whoco mets for such projectswith a contrectorts)licensed pursuant tithe Commemrs ALTI?R-DRAIN&VENT-WATER(G)
License Law. FEE SUMMARY
❑ 1 am exempt under Sec. ,B&PC for this mason BACK FLOW PROTECT.DEVICE OUTSIDE ppn
gPARK
YN
Owner Dam RF,CEIPI'q
DRAINS FLOOR,ROOF,AREA,COND.
• WORKMAN COMPfNlecdco DECLARATION Y N
❑ Ibeabyaenrmon that Insurance ortifedifie copythement omlSeeure,ora,Lm
C.)c te of
which
FlXTURI:S-PER TRAP RECF.IPTp
Wnrkets'Compensntion Insurance orvicenifW copy thereof(Sec.3g(10,LebCJ which YN
aversul1rin yea's tIt t. GAS-1?A.SYSTEM-I INC.40UTLET3Pulicyq JJBUILDING DIVISION FEES
GAS-G.SYSTEM-OVER4(EA) EE
❑ Certified C y is hereby famished.❑ Certified copy is fled with the city inspection division. GREASIVINDUSTRI.WASTE INTERCEPTORCERTIFICATE OF EXEMPTION FROM WORKERS' GRGSETRAP
COMPENSATION INSURANCE
(This section need not becompleted ifthe permit is forme hundreddolluts(EI00) SEWER-SANITARY-STORM EA.200M. ENERGY IEE
orless.)
I certify that in the performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
nut employ any person any manner an as to become subject to the Workers' PAID
Compensation Lawaof Celifomia. Data WATER SYSTEMnRGTING Dam Receipt It
Q Z Applicant
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
r U) become subject o the Workers Compensation Provision of the Labor Code,you most
Tx 1 forthwith comply with such provision.,,his pertniuhell ba domed revoked. BUILDING FEE 609
OW.. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE So
z I hereby affirm that them is a construction lending agency for the performance of TOTAL: ELECTRIC FEE J
U O the work for which this permit is issued(Sec.3097,Civ.CJ
Lenders Name ,
0 I.andcra Address QE'�Y ± �-MECHANICAI;PERMIT a= ` FEE PLUMBING ME
U 1 certify that I have read this application and sore positive above information -'
�" 0. correct.I agree to comply with all city and couny ordinances and state laws reining to PERMITISSUANCE MECHANICAL FEE
building em suuction,and hereby m bmins representatives of this citym enter upon the CONST'RULTION TAX
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MUCH.
(We)agree to save,indemnify and keep harmless the City of Cupertino againt
Iiabilities,judgmenm,costs andexpenxs which may in my way¢crue against mid City AIR HANDLING UNIT(TO JO."CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Applican X7mmaeor Date EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,0110 BTU) Dam Receipt#
Will the upplic ud or furore building occupant store or bundle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) 'TOTAL: ,S U
Cade,Section 25532(a)'t
11 Yes 11 No VENTILATION PAN(SINGLE RISID)
Will the vppiicentorfmurebuildingucupant useequipmrntnrdeviceswhiah emit
BOILER-COMP(31111 OR 100,000 BTU) ISSUANCE DATE
hazardous air commitments in,defnned by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District? PAID A I D
❑Ycs ❑No NEW RESIDENTIAL MECH. SQ.FT. P
I have read the beznNous materials requirements under Chapter 6.95 of the OCTCalifornia E.Int&Safe,,Code,Sections 25505,25533 and 25534. 1 understand that O ���
if the building docs not currently have a tenant,that it is my responsibility to notify the
occupant of the rcquncnrents which most be met prior to Issuance of v Cerifcine of
ccapance�/H
Owner or thonze' Eagent I' Dam TOTAL: ISSUEU BY: Q
OFFICE