26076 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO RUE[)
ILMI -HLEC'IRICAI. PERMU'NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL, n C O�J C
o
BUILDING PROJRCTIDENG v IFTCATTON I
BUILDING ADDRESS: r /� SANITARY NO. AVPLICAaas''II ION SUBB��IMI17AL DATE
Z1 ti`7 '1/'/V/// UNITp LOTp
OWN: A 10 E: I, C to N LIC NO: NIC CO—NTROL#`
RCIII r '/INGINNEEI K: IC ADDRESS: ❑
LONT'ACI: PHONE:
QTY, ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
Iherebyaffrnn Nat l em licensed under provisiansidChupmr9(commencing with JOB DESCRIPTION
�00pfZ Section 7") dDivision 3 of NC Business and Professions Cade.and my liceme is in PANE IS ` �\IJ
its full force and effect. r1`/ +{�
<� license Class Lic.p UP TD 200 AMPS
rn<y Date C.ntmomr 201.1000 AMPS
Z�NZ ARCHITECTS DECLARATION OVER MMAMPS SQ.Pi.FLOOR ARCA E/SQ.FT.
C Z—O I understand my plans shall b,used m public records.
Fm ,� SIGNS ELECTRICAL
hy Licensed Professional
oc M< OWNER.BUILDER DECLARATION SPECIAL CIRCUITIMISC.
K O
to F I hereby affirm that 1 am exempt from the Conuuctar's License Law for the
F�Qrn following reason.(Section)0315,Business and Professions Code:Any city or county TEMP.METER OR POLE INST, k
y which requires a permit to construct,alter,improve.demolish,or repair any swcrurt
>-:E prima.its asmace,.k.requires the applicant for such pnrnitto file.sigdedsutement POWER DEVICES
WcC�J O Om that he is licensed parmant t.the provisions of the Conoactur's License law(Chapter
L p,eW 9(commencing with Section 70010).(Division 3 ofthe Business and Professions Coill SWIMMING POOL ELECTRIC `, VA r ri,rrON
iWe^y or he isesempt therefrom add One basis fermmthe alleged
eged exemption.Any violation of IXTURC CY/aYG/J'
<Y Section 7031.5 by any applicant for a pit subjects the applicant a civil penalty OUTLETS-SWITCHES-F
of rl
G (mare Nad fivehundreddollars(450ty. NEW RESIDENTIAL ELECITt S .
W m n❑ I,mawnerofNepropeny,ormyemploymswiNwagamtheirulecompem.tion. - STORIES TYPECONSTRUC ION
d3— and do lesions and the he Contractor's
Law does of apply in an Business v�
and Professions wh.m Cada:The improves
t eicam,License Law does not apply lf.n owner of
progeny,loym.ldsor improves thereon,undwhod«asuchwdedoo fitted hmugh his
cmpioyen.providedthat such impmvemenuertnm intendedoroffertdfmulc.If, OCC.GROUP RFS. NITS
however,the building orimprovemcnt 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 TOTAL:
uleJ.
El L m nwnerofthe propery,ameaclusively contracting with licensed conment m QTY. PLUMBING PERMIT FET. FLOOD ZONE AI'N
construct the project(Sec.7144,Business and Professions Code:)The Can owara's
License Law does not apply toanownerofpropeny who builds in improvesthereon,and PERMIT ISSUANCE
w ho contmets fur s uch projects with a mnaactogs)licensed pursuant a the Conuacsors
License Low. ALTER-DRAIN&VENT.WATER(EA) FEE SUMMARY
❑ 1.m exempt under Sec. ,B&P C f.r this sent. BACK FLOW PROTECT,DEVICE. OUTSIDE FEES
SANITARY Y
Owner perm
WORKMAN COMPGNSATION DECLARATION DRAINS-Fl.00R,ROOT,AREA,COND, RECEIPTN
SCHOOL TAX YN
❑ Thereby affirm thm lheveacrnifmute ofconunno self-insure,meceniriwu of
FIXTURES-PER TRAP RECEIPTp
covdai Caropli ationlerthis ermit.ted copy thereof(Sa.3800,lab CJwhich PARK FEB Y N
covers all employee's under this permit GAS-I?A.SYS'I'1!M-I INCA OUTLETS RECEIPT M
Plicy M BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cenifiedcopyisherebyfumishcd.
❑ Certified copy is riled with the city inspection division. GREASFANDUSTRL WASTE INTERCEPTOR GRADING FEL!
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This seclummed not he completed ifthe permit is fortune hundred dollars(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the performance of the work for which this Permit is issued.I shall WATER HEATER WNENT/ELECTR
not employ any person in any manner so as to became subject to the WorkersPAID
z Compensation Laws of Califomia. Dau WATER SYSTEMTREATING Date Receipt Of
Applicant
zp NOTICE T'O APPLICANT:If,after making this Ceniricate of Exemption,you should NEW RESIDENTIAL PLM. SQ.Fr. TOTAL:
F .�. become subject to the Workers Compensation provisions of the labor Code,you must
> forthwith comply with such provisiom or this permit shall he deemed revoked. BUILDING FEE
z CONSTRUCTL!
ION LENDING AGENCY SEISMIC FE '
I hereby affirm mundane,is a construction lending agency for the performance of
U O Ne work for which this Perot is issued(Seat.3037,Civ.Cd TOTAL: ELECTRIC FEE
Lk. Lender's Name PLUMBING BEE
U Lender's Address QTY. MECHANICAL PERMIT FEE
1 certify the.I have read this it,licmi.n and sura that the above information is
7" comet Iagreemc.mply with all city andcounty ordinamcesandmmelmwarelating to PERM]TISSUANCE MECHANICAL FEE
rbuilding construction,and hereby amhoriae representatives ofthis city to enter upon the CONSTRUCTION TAX
U Z, above-mentioned Property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and kap fairness the Cit of Cupcnino against
l iuhti 'nd Mme scosu Jcxirens which ma w u rue against said City AIR HANDLING UNIT(TO 10,000 CPM)
nc t ty goft s
AIR HANDLING UNIT(OVER IO,IXp CFM)
'Signature o A lican iatmaor a P.XHAUS'1'HOOD(DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,010 BTU) Dau Raeiptp
Will the applicant or future building occupant amre or handle ha cls ous material
m defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100.000 BTU) T TAI
Code,Section 25532(e)7
11 Yes EI No VENTILATION PAN(SINGLE RESID)
Willthee heart m future buildingacuant use BOILER-COMP(3HP OR 100,001)BTU) ISSUANCE ATE
Pp P Are.Air
Quality
Management hmmdom air conmminnnu m defined by the Day Aun Air Quality Mmugemenl
D'aria7 BOILER-COMP(OVER 1110,000 BTU) ' D
❑Yea ❑No NEW RESIDENTIAL MECH.—SQ.FT.nMAR
�1]]
AIC
I have and the bezna
rdous materials requirements uder Chapter 6 M
.95 of the 1994
California Health&Safety Coda Sections 25505,25533 and 25534. I undersand that
if the building docs not currently have a sneer,than it is my responsibility er notify the
occupantof the requirements which must h mm prior to issuance of a Certificate of LI I Y Ur k.urk
Occupancy.
t amammaiuN agent Date TOTAL: ISSUED Br�ar
OFFICE