26035 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO .,. PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 26035 C O� C
ItU1LDING DIVISION BUILDING PROJECT IDEN'I'IFICAI']ON Lv J
BUILDING ADDRFSS: _ SANITARY NO. APPLICATION SUBMITTAL DATE
n DNITM LOTH
OW 'HSN Mli: PHONE: oa CO RA ORS NAME: t� O' N/C C—O CNTR/Ol.p `
VtCHUECUENGINEER: LIC NO: ADDRESS: ❑ -
FCONTA� PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT UM MECH
PERMIT ISSUANCE ❑ El ❑LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIALTOB DE.SCRI N
py.Zaffirm that l am licensed underpmvisionsofChapter9(commencingwithmOOof Din,17 3 of It Business and Professions Code,and my licentt isin 1 ppNELg~ e act rl FZW lM201T01000 A PSS �Date Convenor I 5ysT! I�F�
-ZFONZ ARCHITECTS DECLARATION OVER 1000 AMPS /� SQ(�I70 ART
R II O V S/SQ.FT.
CZ-0 1 understand my plans shall be used as public records. / \ tl J'�
SIGNS ELECTRICAL _ p� f,�
QQ hiccnScJ Pmfessionul 1 i P II � T 1�, p>.,a(
C OWNER-BUILDER I ant a URDER DECLARATION SPECIAL CIRCUIT/MISC. V IV ISS Y '1
KOy V 1 hereby affirm that 1 am exempt from the Contractor's Calls:tunny law for the
tautly which following iandmpr Professionsh,or
city ormtmty TEP.METER OR POLE INST.
F u O Q which requires a permit re construct,alto,improve,demolish,or mpaig ed swment
he is licensed puhnre the
thea ions of the Co un License
Law(Chapter
POWER DEVICES `-
prim requires pp permi signed
urad to
y�jz�p 9(ommneraimuJpursction7he proDivisinf the Convectors License Law(Chapter
6Ke4 9(cotmnencing with Section]000)of Division3of We Business end Pro&ssinns Code) SWIMMING POOL ELECTRIC VALUATION
W_m or that he is exempt and the basis for the alleged exemption.Any violation of
5ZS< Sectio]031.5 by any applicant for apcmit subjects the applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES
CFO not m...cdonasrive hundred dollars(55W)' rygW RESIDENTIAL ELECfR SQ.FT.
o ❑ I, ownerofthepmp rty,ormyemployeeswitM1wagesastheirsolecompensadon, STORIES TYPECONSTRUCTION
Wao_ will do the work,and the structure is not intended or offered for safe(Sm.]OM,Business
and Professinas Cale:The Committees License Law does not apply to an owner of
property who builds or improves thereon,and who does such work houref m through his
owo employees,provided thatsuch improvements are not intended oroffend forsale.If, OCC.GROUP RES.UNI'T'S
however.the haddingor improvement is sold within one yearofcampletion,the owner-
builder ,will have the burden of that he did not build or int for f TOTAL:
provin8 prove puryoseo
sale).
❑ I,ac owneraf the property.xmendusively mnvaming with licemW convattorsm QTY. PLUMBING PERMIT FEE FLOOD ZONE nPN
construct the project(Sec.7044,Business and Professions Code:)The Contractor
Licenselawdms not apply to an ownerofpropcny who builds or improves theusm,and PERMIT ISSUANCE
whocontmetsfor such projects with acomractor(s)licensed pursued to the Contractors nLTFRDRAINVENT-WATEH
License law. - & TA)) FEE SUMMARY
❑ 1 am exempt under Sec. B&P C for this reason BACK ROW PROTECT.DEVICEOUTSIDE PEES
SANITARY Y N
Owner Date RECEIPT#
COND.AREA.,
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR, SCHOOLTAX Y N
i ❑ Ihereby affirm thmlM1ave ac<rificate of cnnunuo self-insurt,mncmificatc of FIXTURES-PER TRAP RECEIPTp
Workers Compsouroon Insurance or a certified copy thereof(Sec.3801 Lab C.)which PARK FEE Y _ N
savec Ile y under this permit, GAS-EA.SYSTEM-1 INC.40VfETS
L � RT:CIi1Pfp
Policyp Ifo BUILDING DIVISION FEES
Company �b L �� GAS-EA.SYSTEM-OVER4 HDO PLANCHECK FEE
❑ Certified tory copy is ncrWyTffrmished.
❑ Certified ropy is filed with the city inspection division. GREASIVINDUSTRI.WASH INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This seetimmml not be completed ifthep—it is Form hundred dollars(SIM) SEWER-SANITARY-STORM HA.200PT. ENERGYFEE
or Icax.)
I mnify that in the pedommanoe ofthe work for which this pemtit is aimed,l shall WATER HEATER WNENT/ELECIR
not employ any person in any mamrcr u as to become subject to tor WorkersPAID
Z Compensidamlawaof Califon in. Date WATER SYSTENVOREATING Date Proem#
Applicant
z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
(•-' becomesabject mite Worker's Compensation provisions fthe Tabor CWe,you must
a forthwith comply with such provisions m this perium hall be dccmed revoked. BUILDING FEE
(� CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a conswctima lending agency for the performance of
V O the work for which this permit Is issued(Sea 3099,Civ.C.) TOTAL: ELECTRIC FEE
�. Panders Name PLUMBINGEEE Y
F Lenders AddressQTY. MECHANICAL PERMIT FEE
V I certify that I have read this application and state that the above information is MECHANICAL HE
correct. l agree to comply with all city and county ordinances and state laws minting to PERMIT ISSUANCE
I--' building construction,and hereby authorize representatives ofthis city to enter upon the CONSTRUCTION TAX
V Z ahmvutoeromm prnpcny for inspection purposes. ALTER OR ADD TO MECH.
We)agree to save,indemnify and kap hannlesa the City of Cupertino against
liubilitierjudgmenta,emte andexpenses which may inanyway acerae against said City AIR HANDLING UNIT G 010,000 CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER IO.IXNI CPM)
Signature of Applicano/Contractm Date EXHAUST HOOD(WMUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE,
HEATINGUNIT(TO 100,IXIDRTU) Date Rmtm
Will the applicant or future building occupant store or handle harnrdous material HEATING UNIT(OVER 101d"BI'U) TOTAL:
as defired by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Cade.Swtian 25532(x)?
11 Yca 11 Na VENTILATION FAN(SINGLE RF3ID)
ISSUANCE DATE
\ Wilideopplicam-fiame bulldingeccupant uueTipmem ofdevieeswhichemit BOILER-COMP QHP OR M,000 BTU)
incouslous mi contaminans as defined by the Bay Area Air Quality Management BOILER-COMP(OVER IOLOW BTU)
/c1? P N ,
-1 ❑Yes ❑No NEW RESIDENTIAL MECH. SQ.fT. f+
I have read the M1amMOYs materiels requirements under Chapter understood
of the ��
ifthe lmle Health h Safety ently Sections 255(15,25533 and 35s34.I understand the %$ 19
if the building docs not cents w have a tenant,the it is my ssuance of a to notify the f
occupant of the requirements which must be ten prior to issuance of a Cenifica¢off1
0.cupaney. xJ
Owncror authorised agent Date TOTAL ISSUED BY f�'IY f V
OFFICE