26672 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINOPLUMBING
.ISIN4-Ei.E, AL PERMITNO,
CAL
BUILDING DIVISION APPLICATION/PERMIT PLUM BINO-MFIDENTIFICA 26672 6 6 7 2
Bt1FLU1NG i'RUJECI'II3NNTIFICAI'IUN G
BUILDING
ADDRESS: /� / SANITARY NO, APPLICATION SUIIMUTAL UA'1'E
V ifRD4 YY/ UNIT# LOT# -,
PIIONF:I COM' R'S NA E. �, UC NO:
ole .
v J V NIC COMIROLp
• ARCHITECLIiNGINEER: LIC NO: R ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT' FEE BUILOINO PERMIT INFO
BLDG ELECT F14 ME-CH
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES.RESIDEISTIAL JOB DESCRIPTION
qzz I herehyuffinn that lam licensedmtdw provisiomsol'Chapter9(commencing with
+0100 Section 7000)of Division 3 of Ne Business and Profession Code.and my license is in PANELS � Y
WFW [E[[� full force and of / / s 7 1
<Zu) License Clazs 6 I.ic.# �/ / UPTO200AMP5
N Q y Isne Contmcmr 201-1000 AMPS
20'z ARCHITECTS DECLARATION OVER 11100 AMPS SQ.Fr.FLOOR AREA !I/SQ.FT.
O Zvo—q I understand my plans shall be used os public records.
f�
SIGNS ELECTRICAL
Licensed Professional
y ffrc++GG1l OWNER-BUILDER DECLARATION SPECIAL CIRCIII'I'/MISC.
5�0,F 1 hereby effort Char I am exempt froth the Contractor's License Law for the
Is13 n-w following reasna(Smtion]03 t.5.Business and Professions Ctde:Any city or county TEMP.METER OR POLF INST.
F" V, which requires a permit to compact,alter,improve,demolish,or mpvir any awaure
U}� prior to its issuance,also requires the applicant for such Permit to rile a signed statement POWER DEVICES
Pthat he is licensed pursuant to the provisions of the Contractors License Law(Chapter
Ln9(commencing with Section 7000)of Division 3 of the Business and professions Code) SWIMMING POOL ELECTRIC ® B UATIpN
'�_y or that he is exempt thcmfrom and the basis for the alleged exemption.Any violation of
N Section 7031.5b m (cant for t subjects theapplicant at a civil OUTLETS-SWITCHES-FIXTURES t
Z_Q Y Y app i pcomi su lac spenalty of
SS not ml,mowthan freehundreddollormye0). ` /
Fq o Pi
❑ I,azownernfNe ro t NEW RESIDENTIAL ELELTR _S �14 TYPii CONSTRUCTION it
y_ p peawne is yemployewithwagesmtheinol.70m1. union,
3� and Pr the wons C d e The Contin not Initiated Liese La doescal n t apply to an,owner
of
and Profession Code:The Contmcwr's License Law dues not apply lf,t owner of
propertywhobuildsviimprovesthereon,vwhoricessuchworkhimselfor trrough his
ownemployeses. thntsuch improvements menet immntledorolfered trestle.If, ATE RES.UNITS
however,the buildingor improvement is sold within one yearofwmpletion,the ownm
builder will have the burden of covin that he did not build or int for r i`
p g prove p ryoso of
❑ I,azowneroOhe property,am exelusivdycnmreming with licensed contractors to QTY. PLUMBING PERMIT FEE FLOOD ZO f: ANN
crmstrual the project(Sec.7f ,Business and Profession Cade:)The Contractors
I.icense Lawdoesnotapplytomownerofpropenywhobuildsorimpmvesthereon,and PERMIT ISSUANCE
whocomruets mrsuchprojectswithacomhactor(s)Iicenxdpursumt to the Contractors ALTER-DRAW&VENT-WATERER
L oinsel.w. ( ) hEE SUMMARY
❑ 1 am exempt under Sec. ,H&P C for Mis reason BACK FLOW PROTECT.DEVICE SANITARY V N
Owner DataRECEIPT#
• WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA, SCHOOLTAX Y N
❑ Thereby u(ftrn that l have a certificate ofconeenmoself-insure,macerificateof RECEIFI'#
Workers'Cnmpenmtion Insurance oracenifted copy Nereoflgm.3800,Lab C.)which 'M URES-PER TRAP PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company— - C GAS-CA.SYSTEM-OVER 4(EA) PLANCIIECK FEE
❑ Cenllied copy hereby famished.
Certified envy is filed with the Or inspection division. GREASERNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe Permit is Forms hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify thal in the pciformance mf the work for which this Permit is issued,l shall WATER HEATER W/VPNT/ELECLR
not employ any person in any manner eo az to become subjeet to the Workers PAID
Z Compensmionl,uwsof Coliform.. Data WATER SYSTEMfI'RFA'rING DateReceiptg
Applicant
� O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
.I" V) become Subject to the Workers Compensation provision of the Labor Code,you must
forthwith comply with such provision or this North shall be deemed revoked. BUILDING ME
C (� CONSTRUCTION LENDING AGENCY SEISMIC FIDE
'J z I hereby affirm than them is a construction lending agency let the awfomunce of
UO the work for which this permit is issued(See 3097,Civ.C.) T ELECTRICFEE
V. pLenders Name PLUMBING FEC a ^
." Lender's Address QTY, MECHANICAL PERMIT FEE
V I certify that I have read this application and state that the above information is
correct. lugrec mcomply with all ciry andcnmryordinvnees mJsum laws relaungm PERMIT ISSUANCE MECHANICAL FEE
y building construction,and hereby amounts,representatives ofthis city to enter upon Ne CONSTRUCTION TAX
1..) Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save.indemnify and keep hamdess the City of Cupertino against
Iiabilitics,judgmnna,casis and expenses whichmay ninny wayaccrueagaintsaid City AIR HANDLING UNIT(TO 10,(I(H/CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Sigmmme of Applicanl/Conrwoe Date EXHAUST HOOD(W/DUCT) ,
- PAW
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT TO 100,000 BTU) Date Receipt#
Will the applicant or furore buildingsnort or hmWle hazardous mammal
n defrrCaptain.by the Cupco Municipal Cod,.de.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code,Sermon 25532(2)'1
CI Yes ❑No VENTILATION FAN(SINGLE RFSW)
Will theapplicmtorfmart buildingmceupminseequipmemmdeviceswhiehemit
TOILER-COMP LHIP OR 100,000 BTU) ISSUANCE ATE
torments air comannown as defined by the Bay Area Air Quality Managementilk
BOILER-COMP(OVER 100,000 BTU) 4
District?
❑Yes 0 N NEW RESFDESUTAL MECIi. SQ.FT. ��� O
I have read the han ..,crisisdous..,crisis requirement under Chapter 0.95 of the 1994
CNS no Heuhh&Safet Cale,Seciions25505,25533nnd25534. Iunderstcraloot
if the 1, s not ntly have a return,that it is my respnrsibility to notify the CI7Y Ur wre t
roc t of mmo¢which must Iw met pilar I is a oft h I I
captain,
O authorized agent Date TOTAL: ISSUED BY:
OFFICE