26697 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOrl "' PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL: 26697
BUILDING DIVISION ;BUILDING PROJECT IDENTIFICATION ;
BUILDING ADDRESS: .�yV�' SANITARY NO. - APPLICATION SUBMITTAL DATE
C�IUNIT# LOT# e(�
Cost �HO �l RB_ NAME: LIC NO: N/C CCCCC07777NTROLM
ARCHITECT/ENGINEER; - LIC NO: A� i 9\r,4•AR�Rt7&G ❑
coNTnc `pHON =ISSUA�NCE
L'cECT"IC PERMIT x'4# '�'§.FH&§r "' s:'B[jiLUING PERMIT INFO
`LSA `1 JI affi' %4H iv SY.'$d a"§!'.*.*JV t ,• BLDG ELE PLUMB MECH
A �CJ ���7CJ� ` ANCE
LICENSED CONTRACTOR'S DECLARATION -RP.SIDENTIAL JOB DESCRIPTION
ayIhereby affirm thatI am heirsed underprovisions ofChvwr9(commencing with00 Section 9000)of Division 3 ofthe Business and Professions Coda and my license is in U F PoII force and effect.
VLicense Class Lir.# PS Dote Contractor PSOD2 ARCHITECTS DECLARATION MPS SQ.FT.FLOOR AREA g/SQ.FT.
O 1 understand my pleas shall be umd as public record%.
rr•m SIGNS ELECTRICAL
u hmenmd Profesatonal
a
OWNERBUILDERDECLARATION SPECIAL CIRCUIT/MISC.
0.x 00.F- i ngherebyreal afford but 1 am exempt from the Contractor's Co License Law for the
follW✓O H
which
reason.(Section construct,
Business and Professions Code:Any city or county TEMP.METER OR POLE INET.
I"�,n which requires a permit m mnmrven ebur,improve,demoll%M1,m repair any swcmre
.2 > .7 prior to its almarm,aIle rayuirev the applicant for inch permit to file.signed statement POWER DEVICES
that he is licensed croman 1.the provisions of the Contrecmra License Laos,(Chapter
0.p 9(commencing with Section 9000)of Division 3 of the Business and Professions Code) SWMING POOL ELECIR VALUA�
IM
pipC,_y or mat he is exempt therefrom and the basis for thealleged exemption.Any violation of �Q
QSection 7031.5 by any minicam for a permit subjects the applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES o
� � nm more than fee hundred tlbllars($500). NEW RESIDENTIAL ELECfR SQ.
❑ I,esownendmepmpedy,ormyemployees withwagesastheireolecbmpense0on, STORIES TYPE CONSTRUCTION
W willdo the work,and 11m larmureisnodnteadedorOffered fmsale(Sm.70l Business
and Professions Code:The Commcmrs License Law does not apply m an owner of
Property who builds m improves thereon,and who does such work himself or through his
employces,provided matsuch improvements srenotintenderimcffered forsad.If, OCC.GROUP RES.UNITS
however,the buildingorimprovement is sold within one year of completion,the owner-
builder will have the barren of proving that he did but build or improve for purpose of TOTAL:
sale.). sesa,yrft . .• , - F "a
❑ I,as ownerofinepropeny,ant exclusivelycomrncmng wtmlicensedcontracmrst QTY "#pr'y,PLUMBING PERMIT i8i5J- a"+ Er FLOOD ZONE UNITS
construct the project(Soo.9044,Business and Professnns Code:)The Contractor's
Lcense Lawdoes net apply toanownerbfprbperty whnbuildsorimprovesthereon,and PERMIT ISSUANCE
who mmructs for such projects with a contractorbs)licensed pursuvm to the Contractor's
License Law. ALTER-DRAIN&VENT-WATER(EA) _.PEE SUMMARY - -
❑ am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ Ihereby afford that l have acenlficvte ofcousent mmlf-Insure,oracirfificute of FIM'ORES-PER TRAP RECEI #
Workers'Compensution lnemanm oramrti0ed arpy thereof(See.3800,Lab CJ which PARK FEE Y N
covere all employee's under this permit. GAS-EA.SYSTEM-1 IKC.4OUTLETS RECE F#
Policy#
Company BUILDING DIV IGNITES
El Certified copy is hereby furnishGAS-EA.SYSTEM-OOVER HA)
ed. ( 'PLANCHECK FEE
❑ Certified copy is Bled with the city inspection division. GREASIPINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS PEE.
COMPENSATION INSURANCE
("is section amid not W earolleted ifthepermil is for one hundred dollars O UXE SEWER-SANITARY-STORM EA.200FT.
orle".) ENERGY FEE
I certify that in me performance ofthe work for which this permit is issued,Ishan WATER HEATER W/VENT/ELECTR
not employ any person in any number so as m become subject to the Workers' PAID
Compensation Laws of Celifomia. Date WATER SYSTEM/TREATING ate Receipt#
O z Appliant
z Q NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
rV) become subject m the Worker's Compensation provisions of the Labor Code,you must
� ' forthwith comply with such provisions or this permit shall be deemed revoked. BUIL
ped„ A CONSTRUCTION LENDING AGENCY SEISMIC ME Q
a z l hmrby.ff,.that there is it construndon leading egenq fort he perfmmanm of
O O the work for which this permit Is issued(Sea 3099,Civ.C.) TOTAL: ELECTRIC
Qfr Ixnders Name } . gqi - "+ ttq -p
t' Iandms Admvas QTY.` "A ECHANICALPERMIT,"I §IFEgt4 PLUMBI FEE
CJ 1 sentry that I have read this appbcadon end state
that the above Information is 'Rd d"i a e M'd*• ''s` aF by =n T vx
0. correct.l agree to comply with all city and county oMinances and state laws mining to PERMIT ISSUANCE M� ANI AL FEE <
building madmotion,and hereby and aria representatives of this city to emersion the
L) above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CO STRUCTION TAX
(We)ngr m sovq indemnity ad keep harmless orb City of Cbpmioo against
liabilities,] vests andexpenseswhlenmayinany way econmgnimtsaid Ch AIR HANDLING UNIT(TO U),000 CFM)
in wnsul n nntl p
-7 AIR HANDLING UNIT(OVER 10000 CFM)
Sign f AppnecallContractor are EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Receipt#
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 HEAT/NGUNIT(OVER I D(kOpf BTU) T L:
Code,Section 25532(x)?
❑Yes 0 N VENTILATION FAN(SING LERP.SID) 1
BOILER-COMP(311P OR 100,000 BTU) SSUANCE DATE
Will Wbamancnndants as building by the ay Area Am Quality
Manaes geemit D
Ihaznrdoue oir wmeminonm as defined by the Bey Area Air Quality Management BOILER-COMP V
tDismicR (OVER 100,0110 BTU)
❑Yes ❑No NEW RESIDENTIAL MECH.
1 have read the hazardous arm nnis requirements under Chapter 6.95 of the _
Cali fondle Health&Safety Code,Sections 25505,25533 and 25534.I understand that
mcclbuildingdocsmoctaidowhaveatenant,otitis mysuance of. todicat me lV
cc path of the royuiremems which must be at prior to issuance of a Cenifiwm o[ C�`y Ur 4111'CK 1 II
Occupancy.
Owneror annam dagent Date
TOTAL: ISSUED BY:
OFFICE: