26116 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HI ILDI G-ISLET.I'HICA[. PERMITNO.
APPLICATION/PERMIT PLUMBING CT IDENNIFICA 26116
BUILDING DIVISION nIl11.UING PNOJF.C'1'IBIt,NTII+IL'A'1'ION
BUILDING ADDRESS.n:v ,, II /I� _,, Il1'•�/��,( SANITARY NO. APPLICATIONSUBMITT1TAALLLDATE
�� ��� W 1l KILLS Ar/`sV� t`^"V" 1 r'40NITIt LOTH 12 J
OW 'RS NAM I,r I,a Pf10NE: CON CTOR'S A ' LIC NO:
t" lust�C✓\�a.I Qello�cC, Cr-o&26 N/C CONTROL#
\RPUTECTA'NGINEER: LIC NO: ADI iSS: ❑ �I an
. t
CONTACT: PHONE: BUILDING PERMIT INFO
nn I�r�vsw�v ,_,// NN.�. ��}}�� QTY. ELECTRIC PIiRM111T TBP.
W Q �L-sQf elnµ/-+•`ms i2�S -✓��-Y/ PERMIT ISSUANCE BLDG CEl 13 F-1
1'I.UMH MECH
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
nCZ Ihereby affirm that l am licensed underprovisiunsof Chapteril(crmtmencingwith
!x100 Section]000)of Division 3 of Ne Business add Professions Code,add my license is in PANELS
E -fall forceand effect. UP T02fq AMPS
<z License Chas LIC.#
tn<o• Data Contractor 201-I"AMPS
f'v 2 ARCHOECT'S DECLARATION SQ.Fr.FL R AREA E/SQ.FT.
0z OVER IOINIAMPS
O Z I undersand my plans shall a used a public rccnrds. Loe
P' Eq SIGNS ELECTRICAL
(/
a� Licensed Profession al
OWNER-BUILDF.Rrnme CoATION SPECIAL CIRCUIT/MISC.
1xOyIII-O... I hereby d.(S that I am exempt from the Contactor'License Law far the
W 3 te•N
following reason.(Section]0315,Business and Profession Code:Any city or county ]EMP.METER 00.POLE INST.
K.F. g which I,.i..an permit neon.the, plicimprove.demolish.terrepairan,stmnure
N}� prior toe liensedpursurequires Neprovisionofar thesuch Copermino file Licnse La slCimter POWER UI?MCPS
p0 tbm he ix licemedth Sectnua")of ivisi n the themradors add Prelssions raft) SWIMMING POOL ELECTRIC VALUATION
eaxo�e 9(mmmencing with Section 7000)ofDivisian3 o(Ne Businessand Rv(exsiansCMe)
Way or that he is eeempuherefrom and the basis for the alleged exemption.Any violmionof / ' 1 w� r__
EZQ Scaion]031.Sbyany epplicvntfor epcnnitsuhjcerstheepplicuntmacivilpenaltyof OUTLLTS-SWITCHES-PI%'1'URIiS K L
!more Nan rofthedreddollars($S00J.
.oTmyempl NEWRESIDPNTIALELECfR _SQ.FT. STORI' TYPECONSTRUCTION
n❑ omoan five hundred
u t
S
proper y,ormyempended withered forsale(Sm. 044, u mess
d3� add dmhssionse work,aMa:Fthe he Contractors
LiMWarafwrtdfonot apply to an owner
add property
wh oda Costa:The Caatmcmrs License Lew does not apply lf am owner is
property whobuildsorimproves Hereon,mdwho doeasuch wudshimselfor ttwughhf,
employeea,pmvidedthnt auchimprovememn are nmtimendedornf(ercd fnreale.
If, OCC.GROUP RFS.UNITS
k
ebuildingmrimprovemem issold within oeyeuofcompletion,theownerhave the burden of proving that he did not build or improve for purpose ofwnerof the property,am exclusively contracting with licensed contactors to QTY. PLUMBING PERMIT FEE FLOODZONE APN
e project(Sec.7W4,Business and Professions Cade)The Contractor'sdues nm applyto an ownuofpropenywhobuildsmimprovearhereon,andPERMIT ISSUANCE
ence,LtaforaudiproJectawhhuconlructnr(s)lic<roW purnuem to the Con[acmr'e
I iceve Lnw. ALTER-DRAIN A,VENT-WATCH(EA) LYE SUMMARY
❑ I nm exempt under Sea n&P C for Nis reason BACK FLOW PROTECT.DEVICE \ 1'
SANITANY Y N_
:Owner Date DRAINS-MOOR,ROOF',AREACOND. RECHIPfg
WORKMAN COMPENSATION DECLARATION , . SCHOOL TAX Y N
Ihertby off!hail have acenificate of canunnm self-inure,ora cenifemeof RECF.IFT#
FIXTURES-PERTRAP ��
.,hikers'ComPcmation Insurance or a certified copy tbereof(Sec.3800,Lob C.) ch PARK FEE Y N
10 'rovers allem to asunder Nin permit. RECEI
P Y GAS-EA.SYSTEM-1 INC.4 OUTLETS
LNG SION FEES
Policy#
Company
El CertifiW copy is hereby famished. GAS-EA.SYSTEM-OVER 4(EA) PLANCIIEC 0
❑ Certified copy is filW wimme city impaction division. G SRANDUSTRL WASTE INI'F:RCEPTOR GRADING
CERTIFICATE OF EXEMPTION FROM WORKERS' G NASI TRA I� SOI
COMPENSATION INSURANCE '
0 his section need not be completed ifma pconit is Instant,hundred dollars($100) SEWER 1'IAAY-3Ta8f .2 UF'',. �� ENEED FEE
or Tess.)
I codify that in the performance of the work for which this Noun is issued,l shall WATEM IVATER WNF.NT/P.LE
not employ any person in any manner so as to become subject to the Workers '
PAID
Compenauion Laweof Califomia. Date W TER SYS Data
O Z Applicant
7 0 NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should NP. RP_SIDEM'IAL PLMB. SQ,IT. TAL:
haromesubjea to the Workers Compensation provisions of the Latour Cade,you must
a forthwith comply with such provisions or this pe.itshrll be deemed revoked, r�
BUILDING IIiE
w CONSTRUCTION LENDING AGENCY SEISMIC FEE
z
✓✓R I hereby affirm thin here is a construction lending agency for the performance of
L) O the work for which this permit is issued(Sm.LTH],Civ.C.j TOTAL: ELECTRIC FEE
LL. ,r Lenders Nome - PLUMBING PEE
0 V Lenders Address QTY. MECHANICAL PERMIT LYE
I certify that I have read this application and sate that the above information is
H 1 source!. la reemems 1 thallcit andcoum d' a cessadsaalawsrelmin m PERMIT ISSUANCE MECIIANICAI.FEE �w
g PYwi y yor ton g
U"' y building construction.and herebyauN 'umprese toenter upon the(� z above-memin prnpeny fur innpce t p AM ER OR ADD TO MFCI I. CONSTRUCTIONTAX
(We)eg r to ave,indemnify ap hasrmless the City of Name against :22 "
Iiuhiliticr,juA ms,cosa ondexpe se. hichnsayinanywayaa egainstsaid City AIRHANDLINGUNIT(T010,000CFM)
o the granting oft
AIR HANDLING UNIT(OVER 10,00s)CFM)
Sigk1m6fA�oicmnt�oddxcuw Date EXHAUSTHOOD(W/DUCT) PAID
" MATERIALSDISCLOSURE HEATING UNIT(TO 100,01X1 BTU) Date Receipt#riding occupant store or handle havardous materialIIIiATING UNIT(OVIiR lah(100 B'1'Il) TOTAL:
as dby the Cupertino Municipal Code,Chapter 9.12,and the health and Safety
Cade,Section 23332(a)]
❑Yes 1:1 No VENTILATION PAN(SINGLE RF?SID)
Will Neapplicum Orfuturehuilding occupwnuse equipmentordevicerwhicb emit
BOILER-COMP OUP OR 100,00(1 BTU, /s ISSUANCE DATE
hazardous nit containment,as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 1110,000 BTU))Isvid'! m LV e
❑Yea ❑No NEW RESIDENTIAL MECII. SQ.FT. Ir B'�
r. -1
1 have mad the harrSafety
Code,
intones requirements under Chapter understand
of the
California Healthdoes
Safetyendyhave Sections 25505.25533 it is and responsibility
1itytontif that (�8 as. 19
ifcupant of
he esnmments which
ut he etpo is my rsuance oilitymnficat me
or r�sfg -�
occupant of the reyuircmema which moat be met prior to issuance of a Certificate of
(k cursory.
Owner m milamiud agent Date ISSUED BY:
OFFICE