26094 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OFCUPERTINOUIIL)1 .-E HI A, PIERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 2 6 0 9 4
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS:I /' JN SANITARY NO. APP LICATIONSUBMOTL
TALDA•/� V L y � UNIT II LOT#
OW ' N Mli: N"6PHONO CONTR CIO 'S NAME: LIC NO:
N/C CON TROL#
•ARCII1TECf/ENGWE,R: LIC NO: ADDRESS: ,�s ElCONTA T: PHONE: I Lk Y
QTY, ELECTRIC PF,RM IEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MFCH
PERMIT ISSUANCE ❑ 13
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DFSCRIPI' N
py.Z I clebya(fi7m a,tlamlicensdunderpmvisionsof CTapmr9(commendngwith
6100 5 r fikf of Division3of the Hueinesa end Professions Cale,and my licemeis in PANELS
<Z, arae Class
effect. !:
f@'R1 License Class _ Lic.# 6d GP T0200 AMPS
may Dam Conwcmr 201-1030 AMPS
Z FOy RCHITIECTSDECLARATION OVER ItXp AMPS SQ.FT.FLOOR AREA S/SQ.FT.
OZ-0 I understand my plans shall he card m public records.
Licensed Professional SIGNS ELECTRICAL
�y,V OWNER-13GILDERDECLARATION SPECIAL CIRCUIT'/MISC. /— s
xOa 1 hereby affirm that 1 um exempt from the Consomme.License Law for the
W1 o¢n following reason(Section 7(IJLS,Ousinns and Professions Cmge:Any city or county TGMP.ME7ER OR
POLL INST.
t,y Om J which acquires a permit to construct,alter,improve,demolish,or repair any atructum ^ ^ ...,.. ;—
$nsoprior to its issuance,also requires the applicant forsuch permiuo Ne a signed statement POWER DEVICES ) �I ILII i!II
61 K p that he is licensed pursuant to the provisions of the Contractor's Licenar Law(Chapter
6 0 9(commencing wish Section 70W)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATI N
61n o,
or that he is<xempnhcrcfmmand the basis for the alleged exemption.Myviolation of QQTLM, .SWITCHES.FIXTURES
(.-.Z Q Section 7031.1 by any applicum for u permit subject.the applicant m u civil penalty of
^�^�
not mom Nan five hundred dollen(S500). .
C p ❑ 1,samorrol theproperty,ormyemployees with wagesustheirsolecomperomiNEW RESIDHNTIAh IELECI'R on, —SQ FT. STORIES TYPHCONSTRUCTION
yo0 will Pmhewons Code:Th ContranminLnddor Law
dos not apply Loan Business
and Professions Core: pr Contractor's License law des not apply m an owner of
properlywhoecilloviimpmveathereon,ve who doe ssuchworkNmulforthrough his
own employees,provided thmauch improvements ere notimmndedor0fferedforssle.If, OCC.GROUP RFS.UNITS
however,the building or improvement is coldwithin oneyearofeempletien,the owner- TOTAL:
huildcr will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,ns ownerofNe propeny,am exclusively comructing with licensed convacmnro QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
nmman the Project(Sec.7014,Business and Professions Cora:)11e Contractor's FERMI"T ISSUANCE
License Law docs not apply to an ownermproperly who builds or immures thereon,and
whocentncts forsuch projects with acontmmedd licensed pursuant to the Contractors
Lia seLaw, gLTER-DRAIN&VENT-WATGR(EA) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this mason BACK FLOW PROTECT.DEVICE Y lI Mr-
SANITARY N
Owner Data BE—IFr#
DRAINS-FLOOR,ROOF,AREA,COND,
WORKMAN COMPENSATION DECLARATIONSCIIt]O1,TAX Y N
❑ I bemby affirm that l have a certificate ofcomem to self-insum,or a anificam of
LMAPFIXTURES-PGR AP RCCEII'1'#
Workers'Coinpensatiminsumnceoraceniredcopythereof(Sm.38W,
ab C.)which PARK FEE Y e N
covers sell employce's undenhls permih GAS-RA.SYSTLM-I INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby furnished.
❑ Cmified copy is filed with the city inspection division. GRHASERNDUSTRL WASTI3 INTIERCHITOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS I717H
COMPENSATION INSURANCE
(This section.eed not bamodmed Him permit is Forane hundred dolbln(5100) SEWER-SANITARY-STORM EA,20017. ENERGY PEE
or less.)
I certify that in the performance of Ne work for which this permit is issued,)shall WATER HEATER WIVENT/ELECI'R
not employ any person in any manner sec as to become subject to the Workers PAID
Compenxmion Lawsof California. Dam WATER SYSTEMOREA'13NG Dole Receipe#
Z A e
0O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEWRESIDENTIALPLMB. SQ.FT. TOTAL:
Pp] become subject to the Worker's Compensation provisions of the Labor Code you most
Ij forthwith comply with such provisions or this permit a ball IN,deemed rooked, BUILDING FEE
04 fla
w o CONSTRUCTION LENDING AGENCY SEISMIC TLE
Z I hereby affirm that hem is a construction lending agency for the performance of QO
ELECTRIC FEE
0 the work far which this permit is issued(Sec.3097,Civ.CJ
Lenders Name Q PLUMBING TTG F Lenders Address QTY. MECHANICAL PERMIT' FEE
V L certify that I have read this application and state that The above information is
cormet.I ugree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
F^ L,$) building construction,and beady auehoriu representatives of this city menta upon the
V 7 move-mentioned pal for inspection purposes. AI:TIER OR ADD TO MF,CH. CONSTRUCTION TAX
.^� (We)agree to save,indemnify and keep harrWeas Ne City f Coped o against
ASignutum
ments,costs end expenses which am, me ai t� it AIR HANDLING UNIT(TO 10,WCVM)
of the grant) of this emh, AIR HANDLING UNIT(OVER I(I,OW CPM)
plicv ommctor Date EXHAUST HOOD(W/DUCf)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt 9
Will the applicant Or future building occupant sarrc or morale hamrdom material HEATING UNI'I'(OVER 100,000 BTU) T
ns defined by the Cupertino Municipal Cale,Chafer,9,12,end the Health and Safety
Core,Section 25532(0)? VENTILATION PAN(SINGLE REMO)
❑Yes Cl No 71,
Will ehe npplicvntnrfmumbltildingoccupam uuequipmem nnlevicca whichemit
BOILER-COMP OUP OR I W,WO BTU) ISSUANCE DA'Z'E
humorous air comamirtanu as defined by the Bay Area Air Quality Management BOILER-COMP(OVER IW,0BORTIJ)
Disloo?
❑Yes ❑No NEW RESIDENTIAL.MECII. SQ.PT.
I have read the harnrdous nment als regeimnmts under Chapter 6.95 of Ne WAR 4 1994
California Ileultb&Safety Core,Sections 25505,25533 and 25534. 1 understand[bar
if the building Jens not currently have a teem,that it is my responsibility to notify the
Occupant of the rcyuiremenes which must he urn prior m issuomce Of a Certificate of Cl ur- curer,�fl
Occupancy.y. 1V'cJw
Owner m authmived ager Date TOTAL: ISSUED BY:
OFFICE