26668 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ]BUILDING- .L fRl AL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICALCT 26668
BUILDING DIVISION BUILDING PROJECT IDENTIFICA'1'IOR
BU1LDIDII1NGGAADDREESS/( / �( 4^ ' SANITARY NO. APPLICAT/ION�SUBMITTAL DAII
tel/ 54 D U`NIITT,p# LOT#
OWN qMF.: LF__
rs„C� NIC CONTROL#
ARCHI'IECI'pr-NGINEER LIC NO: ADD rS '/Cr-C`• dfL-/ El
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
PERMIT ISSUANCE ❑ 1:1 52
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
Mo4z, I herebyaffirm that l amlicenud underprovisionsofCTapher9(commencing with JOB DESCRIPTION
WOO Sccrinn7")of Dlvr,lm3nflhe Business and Professions Code,And my license is in PANELS
l--00
full force
fZW I.iccal CL-✓ C.q-S�. UP TO 200 AMPS
I n.
jDor Date Convaeto N 201.1000 AMPS
GOyz' ARCHITECTSD A L OVER IOOUAMPS SQ.IT.FLOOR AREA $/SQ.FI'.
O Z an 1 undersland my plam shall be meJ As public records.
FmF; SIGNS ELECTRICAL
Liccnsal Professional
K�yQ OWNER BUILDER DECLARATION SPECIAL CIRCUITIMISC.
KOiv 1 hereby offrm Lha I am exempt from the Cmamctora License Law for the
Wa WON following heasom(Section 7031.5.Business and Pro(Sims Code:Any city orroun,y TEMM
P. ETER OR POLE INST.
�-. < which requites a permit at construct,alter,improve,demolish,or repair any stmchum
,WY7 prior to its issuance,also requires the applicant for such Permit to file a signed statement POWER DEVICES
WK00 that he is licensed pursuant the previsions of the Contractors License Law(Chapter
a Ke 9( commencing with Section 7000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
W—N or that he is exempt herefrom and the basis for the alleged exemption.Any violation of
F Z 2 Section 7031.5 by Any applicant for a permit.ubjects the applicant OUTLETS-SWITCHES-
o a civil penalty of FIXTURES
=W not more Ill=five hunched dollars($500).
C F_p ❑ Lanowacrafthepropeny,ormyemployeeswith wages astheirsolecompereation. NEW RESIDENTIAL ELECTR SQ.IT. STORKS TYPE CONSTRUCTION
y3=° will do the work,and the saaaure is not intandedoroffcred fersale(See.7044,Business
and Professions Care:The Contractor's License Law does not apply to an owner of
property whobuildscrimprovesdaman,andwhoduses such work himselforthrough his
own employees,pravidedthal such improvementsmanot intended oroffcredToraaleIL OCC.GROUP RIS.UNITS
however,the building or improvement is sold within one year of completion,the owner- IPERM
builder will have,the burden of proving that he did not build or improve for purpose of
❑ h m ownerofflepropery,am exclusively calculating with licensed contrctors to QTYPLUMFLOODZONEqPN
nslruct the rject(Sea.70cul.Business and Professions Cab:)Te CmaraccorsLittnse Lawdoesnot apply loan ownermpurmeny who builds or improvestimmon,and PERMIT ISSUANCEwho contracts fofsuch projects with A conturetons)licensed pursuant to the Contractor's Licenu Law. ALTER-DRAIN& FEE SUMMARY
BACK FLOW PROTOUTSIDE FEES
SANITARY YN
Owner Dae DRAIN$-FLOOR,RRECEIPT#
• WORKMAN COMPENSATION meanorm to DECs.1f.i ON SCHOOL TAX Y N
❑ em'Coyaffiationcial Insurance
or ificaleof copyther sclGinsurc,nr Lab C.)camof pIXTURES-PER TRAP RECEIPT#
Workers'C.mpensaeon lnsuance.racenificd copy thereoflSec.3800.Lab C.)which PARK FEE YN
eoversall empil ,+n tM1'
t q GAS-EA.SYSTEM-I INC.4 OUTLETS RF,CEIPT#
Policy p BUILDING DIVISION FEES
1m CentraA �--�rd GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
ur yr hercby�fum�ted�
❑ Certified copy is filed viffide city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS GREASETRAP SOILS FEF.
COMPENSATION INSURANCE
(This section need not her completed if Ne permit is foronchunlmAl dollars IS IOM) SEWER-SANITARY-STORM EA.2WFT. ENERGY FEE
or less.)
I certify that in the perfammnceafthe work for whichlhis permit is issued,l shall MMECHANICALPERMIT
NT/ELECfR
not employ any person in Any manner so as to become subject to the Workers' WPLUMBINOME
z Compensation lawsol'Califomia. Date TING Date
Q Applicant
z 0 NO] 10 APPLICANT:If,after making this Certificate of Exemption,you should MB. SQ.Ff.
,r V] become.subject to the Worker's Compensation provisions of the Labor Code,you must
� ? forthwith comply with such provrwons-1'his permit shall b,Deemed revoked.
LL7 Q CONSTRUCTION LENDING AGENCY
Z I hetvby affirm that them is a construction lending agency for performance of
V O the work far which this Penni,is issued(See3097,Civ.C.) TOTAL:
Lender's Name
QL) Lender%Address QTY. ALPERMIT FEE BINOFEE
U.7 1 certify Ihal 1 have rend this application and sate that the above information is
F-' 4 correct l Ague to comply with at city and county ordinances and stale laws relating to PERM]FISSUANCE MECHANICAL FEE
Ce) building construction,and hereby authorize representatives ofthis city[center upon the a
L.) Z above-metnioncl propeny for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree m save,indemnify and keep harmless the City of Cupertino a ainsl
Inchilities,ju gmcnu,;.s and
c u. hick ayinanywayaecrueagainn - Cif AIR HANDLING UNIT(TO 10,000 CFM)
cyue roof the gaming of this
AIR HANDLING UNIT(OVER IDOOOCFJd) ^�
SlIthmmeM ApphcangCbntraetor am EXHAUST HOOD(W/DUCD
PAID
HA'LARUOUS MATERIALS DISCLOSURE HEATING UNIT I0)"BTU) Dam Receipt#
Will the applicant of future building occupant sort or handle hu>.a s ous material
as defined by the Capetian.Municipal CNe.Chap¢r 9.12,and me Health and Safety HEATING UNIT(OVER IM.000 BTU) TOTAL: ,
Cale.Section 25532p)7
❑Ycs El - VENTILATION FAN(SINGLE RESID)
Will the aconcamorfuture building by themusee MAAirn unlit Mwhichemit
BOILER-COMP(3HP OR IM,"BTU) ISSUANCE DATE
tranDiumG? air contaminants a}defined by the Day Arta Air Quality Management BOILER-
Distria4 COMP(OVER IIXI,f100 BTU)
❑Yes NEW RESIDENTIAL MECH.
I have read the harSafety
Code,
materials requirements under Chapter understand
of the
California Heath&Safety Coda Sections 25505,25533 and 25534. I undcrsland that
if the huilJing Docs mol curently haveatenant.that it is my rcspnnsiJulity to notify e
rcupant of a ICquiremenls wht et 'or I.issuance Of a C ¢a oe
Dana t 7
Owner or amhomcd agent Date TOTAL: ISSUEDB p
OFFICE