26377 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDIN - p PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 26377
BUILDING ALDRESS: SANITARY NO. APPLICATION SUBMITTALTE
DA
b 1 11 I�/��o""J,) UNIT# LOT#
OWNERS NAME: y� PHONE:: CONTRACTOR'S NAME: LIC NO:
CA D L f r,�/�"D' U 64 E LL % S )J /'SJ4W A C I NIC CONTROL#
ARCHITECT/ENGINEER: LIC NO: ADDRESS:
CONTACT: PHONE: BUILDING PERMIT INFO
QTY 8{,ECTgIC PERivi1T FEE
BLDG ELECTPLUM MECH
PERMIT ISSUANCE 44 MKT
LICENSED CONTRACTOR'S DECLARATIONAPPLIANCES-RESIDENTIAL JOB DESCRIPTION
C]W z I hereby affirm that I am licensed under provisions of Chapter 9(commencing with
EWOO Section 7000)of Division 3 of the Business and Professions Code,and my license is in ppNELS
y,W H full force ff
F Z 1 j License Lic.# UP TO 200 AMPS IZAT O���
Lo Q Date Contractor 201-1000 AMPS
H,,z ARCHITECT'S DECLARATION SQ.FT.FLOOR AREA $/SQ.Fr.
O"_ I understand my plans shall be used as public records. OVER 1000 AMPS r
F W SIGNS ELECTRICAL T p n 1
'� Licensed Professional _ 77,
04
OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
O W V I hereby affirm that I am exempt from the Contractor's License Law for the y _, r�j
w O rn following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST. -=� L' IJ t1
< which requires a permit to construct,alter,improve,demolish,or repair any structure
W>-'� prior to its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES Di TE
Al
{
W A O that he is licensed pursuant to the provisions of the Contractors License Law(Chapter
Xo 9(commencing with Section 7000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
or that he is exempt therefrom and the basis for the alleged exemption.Any violation of
[ Z Y' Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of I OUTLETS-SWITCHES-FIXTURES
Qnot more than five hundred dollars($500).
pC,F_ ❑ I,asownerofthe property, y employees g compensation,
NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
p p perry,or m em to ees with wages as theirsole
pW„3 22 will do the work,and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Contractors License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his OCC.GROUP RES.UNITS
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,as owner of the property,am exclusively contracting with licensed contractors to PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7044,Business and Professions Code:)The Contractor's
License Law does not apply to an owner of property who builds or improves thereon,and PERMIT ISSUANCE
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I am exempt under Sec. B&P C for this reason OUTSIDE FEES
BACK FLOW PROTECT.DEVICE
SANITARY Y N
Owner Date DRAINS-FLOORROOFAREACOND. RECEIPT#
, , , .
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ I hereby affirm that I have a certificate of consent to self-insure,or a certificate of FIXTURES-PER TRAP RECEIFIV
Workers'Compensation Insurance or a certified copy thereof(Sec.3800,Lab C.)which PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS REcErr#
Policy# BUILDING DIV ON FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
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 FE
or less.)
I certify that in the performance of the work for which this permit is issued,I shall WATER HEATER W/VENT/ELECTR
not employ any person in any mariner so as to become subject to the Workers' PAID
ompensation Laalife ;� WATER SYSTEM/IREATING Date Receipt#
pplican[
j NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
C/) become subject to the Workers Compensation provisions of the Labor Code,you must
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
4 Q CONSTRUCTION LENDING AGENCY SEISMIC FEE 0
Z I hereby affirm that there is a construction lending agency for the performance of ELECTRIC FEE
O the work for which this permit is issued(Sec.3097,Civ.CJ
�u
Lender's Name
U U Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE �—
LI certify that I have read this application and state that the above information is
.~i a correct.I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL fE l�
y V) building construction,and hereby authorize representatives of this city to enter upon the CONSTRUCTIO TAX
Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
in consequ5wtpf the grantin otib pe
AIR HANDLING UNIT(OVER 10,000 CFM)
21
Signature of Applicant/Contoctor Date EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date eceipt#
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code,Section 25532(a)? VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUA TI CE DATE
Will the applicant or future building occupant use equipment or devices which emit BOILER-COMP(3HP OR 100,000 BTU)
hazardous air contaminants as defined by the Bay Area Au Quality Management BOILER-COMP(OVER 100,000 BTU)
District? ,MAY
i7, 9
' Q/r
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
ci4 �f t� PLH1uY
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534. I understand that
if the building does not currently have a tenant,that it is my responsibility to notify the
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy. �
Owner or authorized agent Date ISSUED BY:
OFFICE