26013APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
I;ITY OF CUPERTINO-
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PRO ECT IDENI'IF CATION
PERMIT NO.
26013
BUILDING ADDRESS:O `
IT11�
GL � %I 1 J vS ��
A TARY NO.
APPLICATIONSUBMITTALDATE
\ / A
OWNERS NAME: PHONE:
CONTRA R'S NAME: LIC NO:
Yy -f y- 'T
FIX
CONI ROLIt
RCHITECDENGINEER: LIC NO:
ADDRESS:
lb
ONTACf: PHONE:
1
v '
QTY: ELQCTRIC PERMIT FEE
A
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
(✓ 4 —O /W
LICENSED CONTRACTOR'S DECLARATION
I herebyru irmthat l am licensed underprovisionsof@apter9(commencingwish
APPLIANCES -RESIDENTIAL
IDB DESCRIPTION
PANELS
Section 7000) of Division J of the Business and Professions Code, and my license is in
I ull foresail eRcn.
License Class Lie. p r
Date Contractus
UPTG 100 AMPS
is
101 -1000 AMPS
ARCHITECTS DECLARATION
SQ. FT. FLOOR AREA $ISQ. FT.
OVER 1000 AMPS
1 understand my plans shall Is, used as public records.
SIGNS ELECTRICAL
^Q�
L D B tl\Y
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
A $aa II V
I hereby affirm that 1 am exempt from the Cosionsor's License law for the
following reason (Section 7031.5, Business and Professions Code: Any city
e rI
,`.%Y
TEMP. A4'IER OR POLE MST. t
structure
price its issuance,
improve, demolish, or repair any omens
n permit re canswm, aalter,pplicant startmant
the cs ofor.uchpermiuorile a
Powell DEVICES
thiorm s be I.licensedpalso nniant to the Licese La
onsi,i License Law (Chapter
than he is licensed punuoono the provisions of Ne Ce Business
9(commencing with Section 7000) of Division Jofthe Business end Professions Code)
I
SWIMMP4G POOL eLeCIRIC DA T
nr that he is a.pt thercfrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicam m a civil Taal ry of
UTLEfS- SWITCHES - FIXTURES
not more than five hundred dollen ($500).
❑ Lasownerofthepropeny,ormyemployeeswithwagesas Nei...lecompeamuon.
NEW RESIDENTIAL ELECfR _SQ. FT.
STORIES
TYPE CONSTRUCTION
will do the work,and themdumm isnotimended oroffered forsale(Sec. 7044, Business
and professions Code: The Contractors License law does not apply to an owner of
property whobuildsorimprovesileravn,and whodoessuch work himselforthrough his
ownempbyces, prnvidulthvt such improvementsertnot in¢ndedoro(fcaW (made. If,
OCC. GROUP
RES. UNITS
however, the building orimprovement is sold within oacyearofeompletion,theownce-
builder will have the burden of proving that he did not build or improve far purpose of
QTY. 'PLUMBING PERMIT FEE
ide.).
❑ I,vsownerofthe MopM,amexclusivelyconimctingwithlicenudwnnmtonus
FLOOD ZONE
APN
construct the project (Sec. 7044. Business and Professions Code) The Contractor's
License law does not apply m an owner of property who bui Ids err improves therum, and
PERMIT ISSUANCE
whocommats forsuch projects with o courtrooms) licensed pursuant othe Contractors
License I.W.
ALTER - DRAIN&VENT - WATER RAE E
FEE SUMMARY
ElI mn exempt under Sec. , B & P C for this mason
BACK FLOW PROTECT. DEVICE
-
OUTSIDE FEES
SANITARY YN
SANITARY
RECEIPT#
Owner Data
DRAINS- FLOOR, ROOF, AREA, COND.
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX YN
1 hereby affirm than 1 have a cmiE<am of consem m xlFinsure, or a cenibcam of
dom Compernsetion Insurance or acertifaed copy mcomf(Sec. 3800, Lab C.) which
ts.Ilemployee's under Nix p<nnil'
Poly M
RECEIPT M
FIXTURES - PER TRAP
PARK FEE Y N
RECEIPT#
GAS - FA. SYSTEM -I INC 4011TLET5
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
❑ Certified cap, is hereby famished.
GREASE(INDUSTRL WASTE INTERCEPTOR
GRADING ME
❑ Certified copy is Glad with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEB
COMPENSATION INSURANCE
SEWER -SANITARY- STORM EA. 201IFT.
ENERGY FEE
(Tlds when madam bscrmpletcd ifthe permit is foronehundreddollan($HX)
or less.)
WATER HEATER W/VENT/ELECTR
I certify that in the performance afthe work ferwhich this permit is issued, L shall
not employ any person in/any maruter an u t bac au the Workers'
PAID
Compewtion Lawso fomi# Date
WATER SYSTEMfTREATING
Data RecciptIt
Applicant f��
NEW RESIDENTIAL PLMIL SQ. FT.
TOTAL:
NOTICE TO APPLe M': If, after making this Certificate of Exemption, you should
Fee... Workds Compewdan previsions of the Labor Cade, you mull
foMwith comply with such provisions or Chia permit shall be deemed revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm datthem iso construction leading agency for be perfammce of
work for which Nis permit is issued (Sec. 3097, Civ. CJ
TOTAL:
ELECTRIC ME
ladder's Name
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
Lenders Address
I minify that 1 have read this application and mute Nat the above information is
correct. l agree to comply with dl city and county ordinances and state laws relating to
PERMIT ISSUANCE
MECHANICAL FER
boilding<anstruction, and hereby authorize representatives of thiacity menterupon me
abave-raentioved pro ie for inspection perforate.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree to S , indemnify and k hmnlesa a City of Cupertino against
Ilubilities,judgm onsmdexpen his n y uyacctueagainstmid City
AIR HANDLING UNIT (TO 10,000 CFM)
wnseyuence grenfing of ' perm
_ 7
AIR HANDLING UNIT (OVER 10,000 CFM)
Signuwre of IicanVCmuad n �
EXHAUST HOOD OVIDUCT)
PAID
HEATING UNIT (TO IN."BTU)
HAZARDOUSM ERIALS DISCLOSURE
Data Receipt#
HEATING UNIT (OVER 100,000 BTU)
TO
W' them"or form building occupant short or handle hazardous material
a' defined by the Calamine Municipal Code. Chapter 9.12. and the Health and Safety
VENTILATION FAN (SINGLE RESIDE
Code, Section 25532(.)7
❑ Yes ❑ No
ISSUANCE DATE
Will theapplicmwrfumrtbuildingoccupant uscequipmenmrdeviceswhich emit
havrdous air conuminms ss defined by the Bay Arta Air Quality Management
whin'!
❑Yes 0 N
BOILER- COME? UHP OR IN," BTU)
PA , D
f
�/]�
BOILER - COMP(OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ. PI'.
I have rand the hassrdous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533 and 25534. I understood N
if the building does nm currently have a tenant, that it is my responsibility m notify the
9
Cat l /A7
• Q�
mention, of the acryiremems which must be met prior to issuance of a Certificate of
Occupcy.
an
u
VLNEH
ISSUED BY:
Owner or emM1oriud again Date
TOTAL:
OFFICE