26961 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ' - PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. /� (� q
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION G J 1
BUILDINGADDR S: SANITARY NO. APP�IONSUBMITTALDATE
UNIT LOT# fxf
OWNERS PHONE: CONT
NIC NAM LIC NO:
O N/C CONTROL#
RCHITP GINECIL - LIC NO: ADDRESS: ❑
CONTACT':, PHONE: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT UMB MUCH
PERMIT ISSUANCE ED
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
M9z Ihemby affirmthatl am licensed underpowisionsof Chaper9(commencingwith JOB DMCRI 'ION
WdEfull forceandof Division Sof the Business and Professions Code,and my license is in ppprElS
I- UC fullforceClad effort UP TO 200 AMPS
a�'
License Class Lic.#
NQy Date Contractor 201-1000 AMPS
Z O-i4 ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O z„a I understand my plans shall be used as public records.
r to SIGNS ELECTRICAL
Licensed Professional
5y Q OWNER-BUILDER DECLARATION SPECIAL CIRL-UIT/MISC.
MU I hereby affirm that I am exempt from the Contractors License Law for the
O ob following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP,METER OR POLE MST.
which requires a permit to consubmt,alcor,improve,demolish,or repair any strartme
Y� prior to its issuance,alaore9uives the applicantforsuch panni¢o file.signeds[acement POWERDEVICES
pp that he is licensed pursuant to the provisions of the Contractors License Law(Chapter
9(commencing with Section 7003)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
iyC)_y or that be is exempt therefmmaol the basis for healleged exemption.Any vmla0on of OUTLETS-SWITCHES-FIXTURES
Section 7031.5 by any applicant fur n permit subjects the applicant to a civil penalty of
e, nut mare than free hundred dollarx yemp. NEW RESIDENTIAL ELECI'R _SQ.PT. STORIES TYPE CONSTRUCTION
m ❑ I,asowm.amhe property,ormyemployeeswithwagesasolo(Sec.cont.Busies
will do the coons and e: heCostructure isao is License
a se ofw doesamd not.(Sec to sur owner of and Professions Cade:The Co lhorear's License Lew does not apply to an owner of
propenywhob,i ovirimprovesthimpmandwlsmnotintmddurofflforthrsug.Ii, OCC GROUP RES.UNITS
employees,p building
or improvement
sold mhinme iatendedmpletiod thea nerf
however,the building or improvement is sold within one year ofcoprove f r t purpose
f TOTAL:
builder will have the huttkn of proving that he did not build or improve for purpose of
ale.).
❑ Las ownerof thepmperty,em exclusively contracting with licensed contractors to QTY. PLUMBING PERMIT PEE FLOOD ZONE APN
consonant the project(Son.7014,Business and I'miesetons Cod,)The Contractors
License Law does not apply to an ownerofproper[y who builds or improves thereon,and PERMIT ISSUANCE
whoconuacts forsnch projects with acontractor(s)licensed pursuant to the Coauaetors ALTER (EA)
License Law. FEE SUMMARY
❑ I am exempt under Sec. ,B&PC for this reasonSID FEES
BACK FLOW PROJECT.DEVICE SANITARY YN
Owner Date RECEIPT#
WORKMAN COMPENSATTON DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOL TAX Y N
❑ I hereby affirm that l have a certificate ofconsent to self-insure,or a certificate of FIXTURES-PER TRAP RECEIPTN
orkers'Compereation Insurance or a certified copy thereof(Sec.3110),Lab C.)which PARK FEE Y N
oven all employee's under this permit - RECEIPT N
Polley# GAS-EA.SYSTEM-I INC.4 OUTLETS a�a BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4 MA) PLANCIECK PEE
❑ Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASFJINDUSTRI,WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION PROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(TTis section random la,completed ifthepermit is fosse hundred dollars($100) SEWER-SANITARY-STORMEA.20(fin. ENERGY FEE
or less.)
I certify that to me performance of Ne work for which this permit is issued,I shall WATER HEATER W/VENT/ELECTR
not employ any .on in any mantra,so as to become subject to the Workers PAID
Compensation Lawsof California. Date - WATER SYSTEMITREATING Dace Receipt#
Z NOTICE
Applicant NEW RESIDENTIAL ELAM. SQ.FT. TOTAL:
NOTICE TO APPLICANT:If,rs after making this Certificate of Exemptia Care,you should
h bechwith c mply the Worker's vismpnuatian p rmisintu ofc d Labor voked. must
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
.7. Z I hereby affirm that hem is a construction lending agency for the performance of
U O the work for which this permit is issued(Sec.3097.Civ.C.) ELECTRIC FEE
w ,r Lenders Name PLUMBING FEF.
O U Lender's Address QTY. MECHANICAL PF.RMTT FEE
, I certify that 1 have read this application and state that Ne above information is MECHANICAL FEE
correct.a ct.l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
,J building comoraction,and herebyantladerepmeenmtivesofthiscity to amerupoathe CONSTRUCTION TAX
U above-mentioned property for inspection purposes, ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Iiabilines,judgmems.co andexpe 'retsaid City AIR HANDLING MIT(TO ,(LOO CFM)
in cornesturannEoft ran'
AIR HANDLING UNI (OVBR IO,OIXI CPM)
Sigm n on m Y EXHAUST NO (W/DUCT) PAID
c HAZARDOUS MATERIA DISCLOSURE HEATING IT(TO100,00)BT l Dute Receiptp
Will the applicant or Poture building occupant store or handle hamrdous macrlal HEATI UNIT(OV 0.1 TU) TOTAL:
as defined by the Cupertino Municipal GMc.Chapter 9.12,and the Health and Safety
Code,Section 25532(m?
11 Yes 11 Na VENTILATI PA ER
ISSUANCE DATE
Will the applicantorfulure buildingoccupantuseeyvipmentordeviceswhich emit BOILER-COM HP OR ,(LOO BTU)
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COME(O R 100,000 BT
District? 1� A
❑Yes ❑Na NEW RESIDENTIAL M H. SQ.FT.
1 have read the hazardous materials requirements under Chapter 6.95 of the AUG 31 1994
ifteCalifornia Health an Safety Code,Sections 25505,t it
and 25534. I understand Na[
if the building does not meetscurrently have a tenant,that it is my responsibility ter notify the
Ooccupant of the requirements which must be met prior to issuance of a Certificate of
cnapancy. CiIY . . „ u
Owner oro thoriud agent Date TOTAL: ISSUED BY:
OFFICE