26093 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO - am,rRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERNIIT PLUMBING-MECHANICAL 26093�O(]�]
BUILDING PROJECT IDENTIFICA'17ON J J
BUILDIN DI)RIrS3' /a� C - SANITARY NO. APPLICATIONSUBMITTALDATE
-V• `J VC LOT M
WN RSN CO O ' N LIC NO:
N/C .CON I RULk
AR II MCT/F.NGINEER: LIC NO: ADDRESS: w...ro F»m ❑
CONTACT': PHONE: l04 ;¢n J "� " ` - x, a?x'BUWDING"PERMIT,INFO
QT ce.EECBTRIC PERMIT FEE 4 .3 -
'BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
WCZ Ihereby affirm tholam licensed underprovisions of Chapter9(commenting with
P409 Scomn 70V).fDi,id,m3of,heBusinessand Professions Code,and my license is in PANELS
full force Class effect. 60 LA�
Q
bull
Clens Lick UP TO 200 AMPS �''�I„�
F a Date Conran mr 201-1 000 AMPS
Fye, ARCHITECTS DECLARATION OVER IOW AMPS SQ.FUFLOORAREA $/SQ.FT.
ZO ZO-Q I understand my phos shall he used as public records. \ Ifs` ® B n A
p4 W SIGNS ELECfI(ICAL h11 I!!L^. 0�1
vc Licensed Professional
damm OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
O p.F 1 hereby affirm that I am exempt from the Contractors License Law for the s\ (�
W 3 W w following reason.(Section 703 1.5,Business and Professions Coda Any city or county TEMP.METER OR POLE INST.
E]0 which requires a permit to censtrucl,alter,improve,demolish,or repair any someone, >
aW'r� pdmwhsis...ace,also requires me applicant for such permit1.fileangned statement POWER DEVICES pA E
W�5 C 0 that he is licensed psuant to the provisions of the Contractor's License Law(Chapter
d0.aSWIMMING POOL ELECTRIC
DON
W or, or that he is exempt herefrom and the basis for The alleged exemption.Any violation of OUTLETS-SWITCHES-FlXTURES
Y Section 7031.5 by any applicant for a Ismaili subjects the applicant to a civil penalty of
0 not mom than five hundred dollars($500).
m C3I,asownernfthepropeny,nrmyempinyeeswiNwages astheirsoler0irperiamion, NEW RESIDENTIAL ELECTR SQ.PT. STORIES TYPE.CONSTRUCTION
pW„3_ will dothework,and the structure isnot intended oroffcred forame(Sce.7144,Business
and Professions Cale:The Contractor's License Law does not apply to an owner of
pmpertywhobuildsodmprovesthereon,andwhodoes such workhimselforthrough his
own eaiployecs,provided due"mcb improvementsammot intendcd.roffered Tussle.If, OCC.GROUP RES.UNITS
hawevee the building.,improvement is sold within one yearofcoaipletiom theowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
s❑)1.as.wnerofthe property,amexclusively contracting with Incensed committeeman, Qat 4 F. tPLUMBINGjPERMIT` + `; a 7 FEE,` FLOOD ZONE APN
onstruct the project(Sec.7044,Business and Professions Code:)' as Contractor's o
License Lawdeesnotapplytoanownerofproperywhobuilelim improves thereon,and PERMIT ISSUANCE
who contracts for such projects withaconhuctorod Iicensedpumuantto the Contractor's ALTER-DRAIN&VENT-
LiceascLuw. WATER(EA) FEESUMMARY -
❑ 1 am exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE UT IDE FEES
SANITARY YN
Owner Dam RECEIPT k
GOND
AREA
ROOF, , .
WORKMAN COMPENSATION DECLARATION DRAINS FLUOR, SCHOOL TAX YN
❑ ent'Compaquart lbmlhaveacertifica fici co yfl msebineure,m aOC.)cale of RECEIPTk
Workers'Compensation Insurance ore certified copy thereof(Sec.3g00,LOC.)which FIXTURES-PER TRAP PARK FEE Y—N
-
covers all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPTk
Policy k iJ BUILDING DIVISION FEES
Company GAS-EA.SYSTEMAVER 4(GA) PLANCHECK FEE
[I Certified copy is hereby famished.
❑ Certified copy is riled with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING ME
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed if the Permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
m 1cm.)
I certify that in The performance ofthe work for which this permit is issued,I shall WATER IIGTER W/VENT/ELECTR
not employ any person in any manner se as to become subject to the Workers' PAID
z Compensation Laws of California. Date WATER SYSTEM/IREATING Date Receipt k
Applicant
���jj 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL FLATS. SQ.FT. TOTAL:
—i .;-1 became subject to the Workers Compensation provisions of the Labor Code,you most
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
W Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
rZ I hereby affirm that hem is a construction lending agency for the Performance of
O the work for which this permit is issued(Seo 3097,Civ C.) ELECTRIC FEE
Lmder,Name g^.p w
Lenders Address QTY.I, s c4MECHANICALPERMIT n ;-:FCB - PLUMBING FEE
LU I certify that I have read riath
s application and state at the above informal s t"'"` t I° `"-
oorreempty MECHANICAL FEE
Qr n.Iagre.to cply with all city and county omtoamers and stale laws rearing to PERMIT ISSUANCE
7 building construction.and hereby authorize representatives of this city m enter upon the CONSTRUCTION TAX
U a above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agraa to save,Indemnify and kwp harmless the Ciry of Cupenam against
liabilities,judgments,costs andexpenses which may in any w ren eagid , id Ciry AIR HANDLING UNIT(TO 10,000 CFM)
In consequent lingo this ll.
AIR HANDLING UNIT(OVER 10,000 CPM)
?"
' ore ofA placid/C.ntracta, ate EXHAUST HOLD(W/DUCT) PAID
HAZARDOUSMA .RIALS DISCLOSURE HEATINGUNIT(TO100,01TOBTU) Date Receiptif
Will the applicant or future building.ccupaut store or handle hazablous material HEATING UNIT(OVER 100,000 BTU) T
as defined by the Cupertino Municipal Code,Chapter 9,12,and the Health and Safety
Code,Section25532(a)^ VENTILATION FAN(SINGLE RBSID)
❑Yes ❑No
BOILER-CAMP(3HPOR 100,000 BTU) P �JSSUAANCE DATE
Will the applibom orfuturebulldiugeacupontm a equipmentordevices which emit H
harnN.us air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
�)ISVIctR MAR
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.IT. M/l�/ _ A 1(I�.f
I have read the hazardous materials requirements under Chapter,6.95.f the kk,�kk•MMMMIIIa• + `S J (f
California Health&Safety Code,Sections 25505,25533 and 25534. I understand that CI f Y tar
if the building does no,curen0y have a tenam,that it is my responsibility to a dify the +Wer h 1114U
occupant the requirements which must bo met prior to Issuance.f a Certificate.f
Occupancy.
Owner or e.umized age. Date TOTAL: ISSUED BY:
OFFIC