26030 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO B ILDIM1.-ELEUI'R1 AI, PERMITNO,
APPLICATION/PERMIT PLUMBING:-MECHANICAL. 26030
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: �/,'�j SANITARY NO. APPLICATION SUBMITTAL DATE
I l i'(�. UNIT# LOT It I� Iq_q%_k
ERS NA, E: PHO'E: C RACfOR'S NAME: LIC NO:
NIC CONTROLX
1 H 'EmiiNGINEER: LIC NO: ADDRESS: ❑
'UrrrACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
PLU
PERMIT ISSUANCE BL X
LICENSED CONTRACTORSmd,,,mDECfARATION APPLIANCESRESIDENTIAL _ iOy pEs�r�'r�
py.Z thereby affirLIfruit CENSE uovisDECL DECLARATION
9(commencing with yGJk��X" ,`•j,[V~1l0
IA00 Section 7000)of Division 3of1he Business and Professions Code.and my license is in PANELS
a 1g.
of force and effml.
fZW License Class Lie# UPTO20AMPS ♦LSs^X�V `QBlryg
to=h Date Commemr 201-UXO AMP SQ.IT.FLOOR AREA r b�/SQ�.FT.
ZOyZ ARCHITECTS DECLARATION OVE 1 M
OZ-0 1 understand my plans shell be used as public records. �� w
putt-11 SIG CAL a
0: Licensed Pnnlessional
9,=� OWNER-BUILDER DECLARATION SPEC CIRCUH'/
XOaU 1 hereby affirm that 1 am exempt from the Contractors License Law for the
W'"W following reason.(Serhom 7031.5.Business and Professions Code:Any city orcounty, .TEMP.METER OR INST.
F-u'O� which requires a pennil to construct,alter,improve,demolish.or repair soy swmurt
SWYFto its issuance,also Yee the licant forsuch l Blcasi Wstarement POWER OF;VICES
K prior rqw pp permi gn
a0 that he is licensed pursuant tothe provisions of the Contrari License Law(Chapter
9commrncin SWIMMING POOL ELECTRIC
( gwith Section]000)of Division 3 ofthe Business and Professions Code) VALUATION
=ot or that he is exempuherefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
US a
Section 703 by any applicant for upan.i,,tbjcct,the ppa licam to eivi l penallyof `
sthoanfivnehudollrs($500)
wnerre .
azNEW RESIDENTIALELECI'R —SQ.FT.
RIPS TYPECONSTRUCTION hp
y3°0 ill Jothework.andtheslmcturcisnm imendeJ oroffereJ forxale lSec.]fN4,Business
and Professions Cade:The Contractors License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
OCCGRO Y RF:SS.UNITS
employees,provided Nat such improvemems are not imended nr offered for sale.If,
however,the building or improvement is sold withinone yearofeempletion,the owner- I
builder will have the harden of proving that he did not build or improve for purpose of
LIn). QTY. .PLUMBING PERMIT FEE FL APN
❑ I,asowncrof thepropcnY.amexdusivNontra
y< ctin8 with sed licenconvaaors to
mrun the project(Sec.7014,Business and Professions Code:)The Contractors r�
License Lawdoes not applyte an owneroTmpeny,who huilds or improves thereon,and PERMIT ISSUANCE
whocontrans for such projects with aconuaeor(s)licensed pursuant to Ne Contmemrs
Licene Law. ALTER-DItA1N&VENT-WATER(FA) P SUMMARY
s
❑ l am exempt under Sec. ,B&P Q for this reason BACK FLOW PROTECT.DEVICIi U951DE FENS
SA AR Y N
Owncr Data RECEIPT#
DRAINS-R.00R,ROOF,AREA,COND,
WORKMAN COMPENSATION DECLARATION SC L YN
❑ thereby affirm thus lhavcucenifcate of conxnuo self-inxure.on certificate of FIXTURES-PER TRAPRECEIPT#
Worker,'Cnmpenmtino Immarceara certified copy thereof(Sec.JBoO,Lab CJ which PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy X BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(U) PUNCHECK FEE
❑ Cenifted copy is hereby fumishei. KOS
❑ Cendied copy is filed with the city inspection division. GRFASUNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPOON FROM WORKERS' GREASE'1'RAP SOILS THE
COMPENSATION INSURANCE
(Thisualnnnncd not he completed if the permit is(arose hundred dollars P$IW) SEWER-SANITARY-STORM EA.200". ENERGY FISH
or lcxs.)
(certify that
pe..un in air,
work for whichesubject is theWlshallker,' WATER HEATER W/VENT/ELECTR
not employ any perssm in any , Dom so as to became subject to the Workers' PAID
Compcnsatiun laws of Califumie. Dae WATER SYSTEM(fRU'1'ING Date Receipt#
zZ Applicant
0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
r00 became subject m the Worker's Compensation provisions of the Labor Code,you most a > forthwith comply with such provisions it or this permshall be deemed revoked. BUILDING FEE
G CONSTRUCTION LENDING AGENCY SEISMIC IgiG
UI hereby affirm that there is a construction lending agency for the performance of z T ELECTRIC PLE
0 the wed for which this permit la isvueA(Sec.JIN];Civ.C.)
Under,Name PLUMBING FEF.
Lenders Address QTY. MECHANICAL PERMIT FEE
U 1 certify than 1 hiwe read this application and state that the above information is / MI?CIIANICAL FF.f3
a rrcev. legrce mcamply with ell city and cnumy ordinances and nate law,relating to PERMITI$$UANCE
F-' building conswction,and hereby authorize repmsenorivesoflhis city on enter upon the CONSTRUCTION TAX
U above-mentioned property for inspection purposes. ALTER OR ADD TO MECIL -
(We)agree m save,indemnify and keep harrdess the City of Cupcnino against
liabilities,judgments.costs and expenses which may in any way seems,against said City AIR HANDLING UNIT(TO 10.000 CFM)
in consequence of the grunting of this petmll.
L AIR HANDLING UNIT(OVER 10,000 CFM)
'Ignamreof Appi i uracmr Date EXHAUST HO(AD(WA)UM) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Date Rei#
Will the applicant or future building Occupant.aom or handle hazardous materiel HEATING UNI'1'(OVER 100,000BTU) low- qn!n
as defined by the Cupertino Municipal Cade,Chapter 9.12,ani the Health and S.cry
Code.Section 25532(a)^ VENTILATION FAN(SINGLE RESID)
❑Yes El No
ISSUANCE DATE
Willlhc epplicantorfmureboilding Occupam useequipmcnmrdcviccswhich<mit
BOILER-COMP(3HP OR 100i"BTU)
hazardous air contaminants as defned by the Bay Area Air Quality Management BOILER-COMP(OVER 100,M)B'TO) a A I D
District?
ClYes C3 No NEW RESIDENTIAL MECH. SQ.FT.
I have mad the haous material,requirements under under Chapter 6.95 of the JAN
zaN19 1994
California 11eaLLM1&Safety Code,Sections 25505,25533 and 25534.I understand that .
if the builJing Joes nm curcntly have a tenant,that it is my responsibilhy m nmify the
Occupant of the requirements which must s,met prior to isuance of a Certificate of CIl Y Ut aur-
eqI)
Occupancy. :4 '
Owncroruutlimixed agent Date A ISSUED BY'
OFFIC