26506 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ut.H.Pimi-RLE. N AL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL, 2 6 5 0
BUILDING PROJECT IDEN'fIF'ICAT6IUN G J v
BUILDING ADDRESSlumbus SANITARY NO. APPLICATIONSUBMITTALDATE
a l !
/ UNIT# LOT#
PHONE: O 'g NAMfi: LIC
N /`c/ 5 NIC CONTROL#
- RCHI'I CT/RNGINMR: LIC NO: R ❑
AVM
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEF.
BLDG ELECT U MECH
PERMIT ISSUANCE ❑ ❑ PQ ❑
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
yz I hereby offirm Nat lam licensed underprovisimotifChepter9(cmormencing with
R Bcetion]000)of_-JC Business anJ Proa Code mylicense is in ppNEIS
C V full p: roti office
aZ License CP Lic.0 f � UP T02W AMPS
y 6 d pore Contmmm 201-1000 AMP, v
AFRCHITEC'PS DECIARA ION SQ.Ff.FLOOR AREA VSQ.FT.
-,4 Oy3 OVER IWO AMPS
1 understand my plans shall be used axpublic records.
Z�
SIGNS ELECTRICAL
<� I Licensed Professiond
d'yk.0 OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
KOy V I hereby affirm that 1 an exempt from the Comlructor's License Law for the
u134rfgfollowingreamn.(Section 7031.5.Business and Professions Code:My city orcounty TEMP.METER OR POLL INS'f.
which requires a mor Ino construct,alter,improve,demolish,m rtpair any sanctum
W}Mto its issuance,also the applicant fmrsuch tat Men sipped mmpent POWER DEVICES
print quires pp panni ,Lads
pz that m is licensed pursuant m the provisions of the he Business
usi ass License Law(shaper
L�axeLL 9(mmmencingwith Section]0ndthe Division 3opheod emsandtic Professions Code) SWIMMING POOL ELECTRIC VALUATION
or for W_y Seefiche31.5 by tsherefmmand the Permfonhetsthedexemant to civilpintionof OUTLETS-SWITCHES-FI%TURFS
Ya Se<rion]OI LS by myepplicmtfora Permit subjects the epplicunumacivil penaltyof
Dat more than Gro hundred 0 dollars($500). NEW RF:SIDENTIAI.ELECfR _SQ.FT. ,TORIES PECONSTRUMION
W0 ❑ I,asownemfsheproperty.mrmyemployees wilhweges as Neirsolecompemation,
i will doth work,andeh no anis License
dm
appy to an Business
J anti Professions Cnde:The Contracmrs Liceve Lew tion not apply w m owner of
propertywhohuildsm improvers thereon,andwhodoessuchwork himselforthrough his OCC.GROUP RFS.UNITS
wn employces,pmvided that such i mprov emmts are not intended m offered for sale.If, Is
however,she building or improvement is sold within meyem ofcompletion,themwner- TOTAL:
builder will have the burdm of proving that he did not build or improve for purpose of
sale).
❑ I.res uwnerofdm property,amexclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEE OF .ZONE APN
nnsauct the project(Sec.7W4,Business and Professions Code:)The Contractors PERMIT ISSUANCE
License Lawdms not apply m.m Owmmofproperty wh.lo ildami pomves therem,and
who commas for such projects wish acontractor(s)licensed purauanttothe Conuactora
License Law. AIALTER-DRN&VENT-WATER(FA) FEE SUMMARY
[I1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUISIDEF.E
SANITARY Y N_
Owner Date RECF.IPf#
WORKMAN COMPENSATION DnARATION DRAINS-FLOOR.ROOF,AREA.COND
SCHOOLTA% Y
N
Inmtn iFiewc coneimeO . iFXTURES-PER TRAP RECEIPT#
Workers Compensation Insurance oraron0ied copy thereof(Sc.380 ,Lab C)which
PARK FF.F: YN
overs all empluyy re d /r-Vi-a� GAS-FA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy#------�' 1[//llr OGa-JL1BUILDING DIVISION FEES
Com CCcnifiGAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ ed copy ix rtby famished.
P—In"fied copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF LXL'MPDON FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section neerl nut becompleted ifthe permit is forme humdreddollme($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
orlcss.)
Icorlify,hia in the Fermor mnceofthe work for which Nis Permit is issued,IshallWATER HEATER W/VEJT/ELECTR
not employ any person in any manner so as to become subject to the Workers' 7 PAID
Compensmlontawsof Califamia. Date WATER SYSTEM?REATING Date Receipt#
z Applicant
z0 NOTICE TOAPPLICANT:If,after makingthis Certificate ofExemption,you should NEW RESIDENTIAL PLMB. SQ.Ff. TOTAL:
sem. become subim to the Worker's Cmmprandon provisions of the labor Code,you must
> forthwith comply wish such provisions.,his permit shall Ile em
deed revoked. BUILDING FEE
Til . CONSTRUCTION LENDING AGENCY SEISMIC ME
z I hereby Lffirm that there is a construction lending agency for the performance of -
O to work for which this permit is issued(Sec.3091,Civ.C.) TOTAL: ELECTRIC FEE
Lender's Name
OF Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
LII I certify Nat 1 have mad thus application and standar the above infommtion is MECHANICAL FEE
t]w correct.l agree to comply with all city and county ordinances and stem laws relating to PERMIT ISSUANCE
1,0 buildingcanstmction,mdhereby auNmim mpmsentativcs ofthis city to enter upon the CONS'IRUCTIONTAX
Vabove-mentioned property for inspection purposes. ALTERORADDTOMF.CH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Iiabilitin.judgmenta.musts and expenses which may in any way immeegainst said City AIR HANDLING UNIT(TO 10.031)CFM)
in cu eoence of the fthis IL AIR HANDLING UNIT(OVER 10."CFM))
Signatureof Ap ' mmctor a� EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 10.000 BTU) Dam Receipt
Will she applicant mfuture building occupant store or handle hazmdous material FIEATING UNIT(OVER IOLXXI BTU) TOTAL:
m defined by the Cupertino Municipal Cade,Chapter 9,12,and the Health and Safety
Code,Seem.25532(x)1
11 Yes 11 No VENTILATION PAN(SINGLE RESID)
ISSUANCE DATE
Will theupplicanmrfummbuildingmcupant useequipmemordekoctwhich emit BOILER-COMP IMP OR Uft"BTU) -
hazardeus dr commininanls as dented by the Bay Arms Air Quality Management BOILER-COMP(OVER IW.mBTU) RECEIVED;
16lrIClT
❑Yes ❑No NEW RESIDENTIAL MECH.-SQ.FT.
1 have mad the harsdous materials requirements under Chapter 6.95 of the �L I �s 'J 1994
California Health&Safety Code,Sections 25505,25533 and 25534.I understand that
if the building dos not currently have a tenant.that it is my responsibility to notify the BITY DE CUPMIKO
occupant of the requirements which must be met prim to issuance of a Certificate of
Dccupamcy. I�WIIaINfi DfP7.
Owner or authorized agent Dam � TOTAL: ISSUED BY:JJ]
OFFICE