26023APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO APPLICATION/PERMIT
BUILDING DIVISION PLUMBING -MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMIT No. �' O
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SANITARY NO.
ISSUUBMIITTAL DAT
APPLICATIONE.
11 LL V 11..
OWNF NAME: ts IsI� ,Jy PH NE: yCONTRACTOR'g
�7llr /GL_
NAME: LIC NO:
NBC
CONTROL R
RCI I'T Cl/LbOd EER: LIC NO: -
ADDRESS:
❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
ELECT PLUMB MELD
PERMIT ISSUANCE
El El
LICENSED CONTRACTOR'S DECLARATION
I herebyieffirmthat l amlicensed underprovisium of Chapter9(commencingwith
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
Section 7000) of Division 3 ofthe Business and Professions Code, and my license is in
full force and effect.
PANELS
License Class Lic.If
UP TO 200 AMPS
Date Contractor
201 - 1000 AMPS
ARCHITECTS DECLARATION
1 understand my plana shall be used as public records.
OVER IM AMPS
SQ. PT. MOOR AREA
$,'SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
1 hereby affi. that 1 an exempt Dom the Connector's License Law for rise
—,
TEMP. METER OR POLE INST.
following reason,(Section703L5, Business and Prrfnssions Code: Any citymcoumy
which reclaims a permit to construct, alter, improve, demolish, or repair any structure
prioneirs issuance, also requiresthe applicant forsuch pemriuofleasigned statement
POWER DEVICES
.
that he is licensed pursuant m the provisions of the Contractors License Law (Chapter
9(commencing with Section 7000) of Division 3 of the Business and Professions Code)
SWIMMING POOL ELECTRIC
VALUATION
or that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Srebro 7 1.5 by any applicant for a permit suhjects the applicant m a civil perealty of
OUTLETS - SWITCHES - FIXTURES
not thanfive hundred dollars my employees
I,thewrk,
NEW RESIDENTIAL ELECfR — SQ. FT.
STORIES
TYPE CONSTRUCTION
and the so earurmyemployeeswithwagesasthei(Sec. 7044, Business
will domesions and the he Contractors
ofw dooed orsalepply 7044, owner of
License
and Professions Cade: The Connectors License Lew does not apply m an owner of
p //v p 0E+ D
J \III, Ill
IY ■ I
IOL�Vp
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properly whobuildsorimprovesthercon,and whodceaauchwrrk himselfarthroughhie
own employees, providedthat such improvemenuar, not itnendedmicfferedforsde. If,
_however, Ne building orimprevement is sold within one yearo(completion, the owner-
builder will have the burden of proving that he did not build or improve for purpose of
dfl
\ OCC R R.�.
1I 1
a /u �+ tl
i
rr... RES.
Grs,.al+
UNITS
TOTA
QTY. PLUMBING PERMIT FE
®AT
❑ 1,ct
amexdusivelycoimitaiions;
Q Z
'
PN
the project(See704 Code)Th Contractors
kenscoustret the project (Sec. oano Business and ywhobiotts Crim The Contractor's
Li cense Law does am aPl y to an owner of properly who bui Ids rs improves thereon, end
__J
PERMIT ISSUANCE —
License raw. for such projects withacontractor(s) licensed porsuantmthe Conbacmr's
License Law.
ALTER
FEE SUMMARY
❑ 1 am exempt ander Sec. , B & P C for this reason
BACK FLOW PROTECT, DEVICE
OI SIDE FEES
SANITARY Y N
RECEIPT#
Owner - - Date
DRAINS - FLOOR, ROOF, AREA, COND.
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX YN
Cl Ihereby affrmthat l have acertificauofemsentmself-insure, oracertificateof
Wmkeri Compensa[ion lnkurenceoracenified copy thereof(SecJB00,Leb CJ which
RECEIPTN
FlXTURC•S - PER TRAP
PARKFEE YN
ars all employee's order this Permit.
Policy #
GAS - EA. SYSTEM -I INC. 4 OUTLETS
RECEIPTS
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
❑ Certified copy is hereby furnished.
GREASMNDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Codified copy is filed with the city inspection division.
CERTIFICATEOFEXEMPTIONFROMWORKERS'
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
(This section need cruise completed ifthepennit is for one hundmaddollars($100)
or less.)
WATER HEATER WIVENDELECTR
I codify that in the performance of the work for which this permit is issued, I shall
Net employ any person in soy marmer so as m become subject to the Workers
PAID
Compensation Lawsof Califomia. Dare
WATER SYSTEM/IREATING
Date Receipt#
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
NEW RESIDENTIAL PLMIL SQ. FT.
TOTAL:
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall he deemed revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a eartmuctien lending agency for Ne performance of
the work for which this Penni, is issued (Sm. 3097, Civ. C.)
TOTAL:
ELECTRIC FEE
Lender's Name
Lender's Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
1 certify that I have read this application and sae that the above information is
correct, I agree to comply with all city and county ordinances and state laws relating to
PERMIT ISSUANCE
MECHANICAL FEE
buildingconanucuion, and hereby authonimmism motives ofthiscity in enterupon the
ab
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities,judgmems, costs andexpenseswhich may 'no n aymeueaga'und City
AIR HANDLING MIT (TO IQOWCFM)
in end of the granting of noir.
a ��
AIR HANDLING UNIT (OVER 10,000 CFM)
i'Sigradaill,NApplicanoConerader v f5am I
EXHAUST HOOD(W/DUCT)
PAID
HEATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dau Receipt#
HEATING UNIT (OVER 100,000 BTU)
TAL
Will the appli mu m future building occupant score or handle haardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
VENTILATION FAN (SING LE RESID)
'
Code, Section 25532(x)1
❑ Yes 11 No
ISSUANCE DATE
Willtheapplicenmrfurure huildingowupanuuseequlpmentordevic<e which emit
haardtius air contaminantspp
as defined by the Bay Am Air Quality Management
D xmetp
BOILER - COMP (3UP OR 100,00(Ir BTU)
p .
A
T D
BOILER-COMP(OVER 100,000 BTU)
NEW RESIDENTIAL MECH.—SQ. FT.
❑ Yea ❑ No
1 ����
I have rend the hairedous materials requirements under Chapter 6.95 of the
JAI i
Califomia Health & Safety Code, Sections 25505, 25533 end 25534. I understand that
if the buildingthatins myresponsibilitytonotifythe
e a must
iccupanitdingdmanmcunts ly which
i of the requirements which must tenant, met prior m issuance of it Ce notify of e
rttt ��/�j�,'�\
CITY Ur VV IIIV z--Y�
,
Occupancy.
1`/
ISSUED BY: "U
Owner or authorized agent Dam
TOTAL: