26274 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-NLN(;I'RICA L PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL n A
BUILDING DIVISION NUILDINI;PN(IJN(TT IIINN"fINICATION L 4
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
Ob z �✓ UNIT# LOT N R... I %t
OWN RS NAME: ZONE: DR'S NAME: I.IC NO:
17gq /A NC CONTROLp
�R T - dESS
I -NEER: LIC NO:
CONT .'LPHONE: QTY. ELECT CPERMIT FEE BUILDING PERMIT INFO
�Abt/ .;2, .,IO�� PERMITISSUANCE J BLDG ELECT PLUM 'CIi
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL 700lTOB DESCRIPTION
17CZ Iherebyaffitm that l am licensed underpmvisionerfatipler9(commencing with
1+100 Section J00Division 3 of.heBusincssand Professions Code,and my license isin PANELS
KU full force and effect. �rrrj
04 t se a. I.IC.N f• UPT0200AMPS
LicenCl -N wIY�/`7•�.%
m Q eo Date Contractor 201-1000 AMPS
�yzARCHITECTS DECLARATION SQ.FT FLOOR AREA E/SQ.FT,
ZOm— OVER 1000 AMPS
OZ-0 lundersland myplarusholl he.sodas publienersims.
SIGNS ELECTRICAL
License)Professional
IY IycdQ OWNER.BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
a Oa FU 1 hereby ofibm that 1 nm exempt from the Comrucmr's License Law for the
Ixt131'.h following reason.(Scetion 7031.5,Business and Profesxions QMa:Any city or county TEMP.METER OR POLEINST.
u'Oa which requires a permit tot construct,alter,improve,demolish,or repair any structure
CW>� plirm its isxara,c.jd,o requires the uppliwm morecohpemdl m filesslguedasuement POWER DEVICES
µ1G0 Ihm he is licened purmannn the pnwi.onnspf the Contractor's License Law(Chapter SWIMMING POOL T:LECTRIC
de.o�' 9(commencing wiib Section 7000)of Div inner 3 of the Business and Professions Gale) VALUAI OPJZ
W=h puha he is exnnpl lhcrcfmm mAlhc hasis for the allege)exemption.Anyvirdith not UTLETS.SWITCHNSJgXTURliS
FZa Section](131 Shy any applicant linupermit.vubjens the applicantmacivil penalty of
ceyp not mLasownfiol The prnldollormyci0). NEW RESIDENTIAL ELECIR _SQ.FP. STORE TYPE:CONSTRUCT ION
WF-� ❑ Lasnwncrnl thepmpcnY,ormycmpley¢a with wngesastheirsolecompcnsmion,
a3= will do the work,and the structure is not intended proffered for sale(See 9044,Business
and Professions Code:The Contractor's License law does not apply to an owner of Do
II Eac
property wM10 builds orimpmves thereon,and wM1od«such work himselforlhrough his I II
employs.providedthalxuchimpmvementsurcnulimmd
endWoroffeformlelf, [ p OF k1iS.UNITS
however,the building or improvemcm is sold within one yearofcompletion.the owner- L: n Ft �y��� II--�� I'UII
builder will have the burden of proving that he did not build or improve for pry
uose of F II Il
sale.). QTY. PLUMBING PERMIT FEE APN
❑ 1,aspwncrofthepropeny,emexdusivcycontraaingwithlicensedcontmcmrsm E
onstmcl the project(See.7044,Business and Professions Code:)The Contractors
License Lawd«s not apply losnowncrofpcn
ropy whobuildsorimproves thereon,and PERMIT ISSUANCE
adocoae
tms for rs lmmro
such pmjecwith a rscr(s)licensedrs
puuanttothe Contractor's ALTER LA
License Law. 1 ) FEE SUMMARY
❑ 1 am exempt under Sec. .B&P C for this notion OUTSIDE FEES
gpCK FLOW PROTECT.DEVICE
SANITARY Y N
OwnerDale RECEIPT to
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF.AREA,CONE. SCHOOLTAX Y N
❑ Iherebyaf rm that i have acenificate efcoment to self-insure.oraccNficateof RECEIFT#
FlXTIIRFS-PER TRAP
PARK FEE Y
Workers'Compcnmtion Insurance or a cenified copy thereof(Sec.3800.Lab CJ which N
covers all employee's under this permit. GAS-EA.SYSTHM-I INC.4 OUTLETS RECEIPT p
Policy# BUILDING DIV SION
Company GAS-EA.SYSTEM OVER 4(EA) PLANCHECK FEF
❑ 'Certified copy is hereby fumixhed.
❑ Certified copy is fled with the city inspection division. GREASEdNDUSTRL WASTE INTERCEPTOR GRADING FEE
CF.R'I'IFICA1'I!OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSA'DON INSURANCE
(Tlgssenlonnced mol he completed ifthe pump is from,hundred imIlars(1100) SEWER s SANITARY-STORM EA.200I11'. ENERGY FEE
or loss.)
I certify that in the perltmamoo ofdoe work for whichdis permit is issued,l shall WATER HEATER W/VENTELECTR
not employ any Penson in any manner so as in became subject to the WorkerPAID
Compuxmion Luws of Culifomia. (late WATER SYSTEM/1'REATING Date Receipt#
O z Applicant
z 0 NOTICHTOAPPLICANT:If,after making this Cenificateof Exemption,you should NEW RESIDENMALPI.MB, SR Is[. TOTAL:
o. becpmesubjcctruhc WorkenCompens�ti�n previsions ofthe Labor Code,you must
> fnnhwith comply with such provisions pr this permit xhall be deemed revoked. BUILDING FEE
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
7 z Ihereby affirm0mthere isucpmtrjeipn lending agency for the performance of ELECTRIC FEE
U U the work for which this permit is issued(See 3097,Civ.C.)
Lenders Name
0 F Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE �+
U I certify that I love read this ap,licminn and state that the above mfnnnation is MECHANICAL FEE
7" concct. PERMIT ISSUANCE,
building conslmmion,and hereby omhoriu mpmunutives of Niscitytacnmrupolnhe
above-memioned propenY for inspection ALTER OR ADD TO MECH. CONSTRUCf10N TAX
(j z pec ten p Cep harr
(We)agree,m save,indemnify and keep marrnless the City co Cupertino against
liabiliti judgments,toxo and exp<nacs which nay in any way accrvugainst said City AIR HANDLING UNIT(TO 10.000 CIM)
in con. the granting of this permit.
AIR HANDLING UNIT(OVER IQOp CFM)
S' reef ApplicanUContractnr I rate EXHAUST FOOD(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,0110 BTU) Date Receipt#
Will the applicant or future building occupant store or handle hazardous material O
10.
as defined by the Cupertino Municipal Cords,Chapter 9.12,and Me Health and Safety HEATING UNIT(OVER 100,000 BTU)
Code,Section 25532(x)] VENTILATION FAN(SINGLE RESID) 1
❑Yes ❑No '1
BOILER-COMP OFF OR IOBW80 BTU) pS •ANCE AT
-
Will Iheapplicminr future building«cupanmuequipmenmrdeviceswhich emit f�
)zardous air cormmmonals m defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
iwiri? 1319
❑Ys" ❑No NEW RESIDENI'IAI.MECH.—SQ,W. PR
1 have read the h-cadoas mmeri:ds reciannems under Claims,6.95 of the A 'CNEIIVC)
California health&Safety Code,Sections 25505.25533 and 25534. l under vain i that r tr VUr
ifthe hulldingd requir uents whichly air be let poi ra issuance of
lonodfyme - 4��� V
cuplmt el the fes not cornu which must armee trips to issuance of a Certificate of
he
Occupancy.
Owner or umhorized agent Date ISSUED BY:
OFFICE `