26058 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY F
tl ILI3IN -.—L1 RI A. PERMIT NO. 26058
S ^ O V H
CITY OF CUPERTINO PLUMBING-MECHANICAL '2 Y6
xUD.mNG DrvIS10N APPLICATION/PERMIT BUILDING PRO RCIADRNTIFICA•TLON
BUILDING ADDRESS: �/ SANITARY NO. APPLICATION SUBMITTAL DATE
tE�IENGINEER:
70N9T'A- �- r/ UNIT# LOT# QgLv
r � CONTOCfZNceE&_ LIC NO:LIC NO: ADDRESS: �VIaL�PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
PLUG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑ED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
OKZ I hereby affirm that am licensed underprovisions of Chapta9(commencing with
WOO Section 7WO)of Division 3 of the Business end Professions Cole,and my license is in PANELS - -nw\ln
ty,tale full force and effat. }� f7 irVsYl�.�u
U UP T02W AMPS t*% ` QWAIA
`'
raZ� License Class Lia#
m?v4i Date Contractor 201-IOW AMPS gQ,FC FLOOR AREA S/SQ.FT.
ZOyZ ARCHITECTS DECLARATION OVER 1000 AMPS +�. I' I� ' a 'I Va
O Z^0 I understand my plans shall be used as public mcords.
ryFu.]t SIGNS ELECTRICAL r l n ..-,
Fin
a5dCL
E.4 Licensed Professional
5{ mu OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MIS _
Oy 1 hereby off.that]an exempt from the Cormalme,License Law for the
3
M,t; following (Section 7031.5.Business and Prafessiom Code:My city or county TEMP.METER OR POLE INS .._ _
fIr'
05 which mquires n permit to construct,alter,improve,demolish,or repair any structure
w}� prior m its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES. J
�y<0 that he is licensed lan to the provisions ofthe Contractors License Law(Chapter SWIMMING POOL ELECTRIC VA ON
1e tx, 9(commencing with Section 7")of Division 3 of the Business and Professions Code?
0My or that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Y Section 7031.5 by an applicant remit subjects theapplicant to a civil OUTLETS-SWITCHES-Fl%TURES
FZ_a my Pe 1penalty of
not than Ove M1undrcd dollars(SSW).
� q NEW RFSIDGNTIAf.ELECIR _SQ.FT. STORIES TYPE CONSTRUCTION
eosork,atheestracy,ormyempendedwifferad rrame(Sw.c0mpBusiness
ill work,end the she Comment intended Law
dos not apply t oan Business
end Professinm Code:The Commences License Lew d«s not apply to an owner of
pmpeny who builds or improves thereon,end who docs such work himself or through Itis
ownemployua,providedthauuchimprovcmemsare notimendedoroffcredforale.IL OCC.GROUP REB.UNITS
however,fire building or improvement is sold within one yearofcompletion,theowner. TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.). QTY. PLUMBING PERh11T FEE
wFLOODZON APN
CII,asowneroftbepmp ny,amexclusivelycontactingwithlicensedconhactorsto
onsct the project(Sec.]044,Business and Professions Code:)The Contractor's
License Lewd«snm apply manownermfpropeny whotimidsorimprovestioreon,end PERMIT ISSUANCE
who contacts forsuch projects with ac«tractorfs)licensed purmanam the Cmarmors ALTER-DRAIN&VF-NT-WATER(EA) FEE SUMMARY
License Law.
❑ l em exempt under Sa. ,B&P C for this mason BACK FLOW PROTECT.DEVICE SID ES
SANITARY Y N
Owner Date RECIiI PT
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF.AREA,GOND. SCHOOLTAX Y N
❑ I hembyaffrm that l have a certificate ofcoment to self-insure,ora certificate of FIXTURES-PER TRAP RECLIPI'p
PARK FEE
Workea'Courpertotlon Insurance ora certified copy thereof(Sec.1100,Lab C)which RECEIPT# N
covers all employee.under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS
BUILDING DIVISION FEES
Policy#
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ CCrtlficd copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GRF.ASE(NDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIPICAM OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thissection need not be completed]fthe permit is frrone hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I cenifythat in the permrmeneeof the work for which this permit is issued,l shall WATER HEATER WIVENT/ELECIR
not employ any Person in any manner so m to become subject to the Workers' PAID
Compemation Lawsof California. Date WATER SYSTEIMi BEATING Dame Receipt#
O Z' Applicant
z - NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDI?NTIAL PLMB. SU FT. TOTAL:
r IA become subject to the Worker's Compensation provisions ofthe labor Code.you must BUILDING FEE
forthwith comply with such Provisions or this permit Noll be deemed revoked.
G Q CONSTRUC ION LENDING AGENCY SEISMIC FEF.
1 hereby option that them is o construction lending agency for the performance of
U O TOTAL: GLECfRIC FEB
the work for which this permit is issued(Sec.309].Civ.CJ
Lender's Name PLUMBING Mr.
0 F Lenders Address QTY, MECHANICAL PERMIT FEE
O U I certify that I have read this application and state that the move information is MECHANICAL FEE
>" Lk1 emonet.legrceto comply withal)city and county ordinances and smte laws miming to PERMIT ISSUANCE
U building construction,and hereby suthnda reprcsenutivesofthisciry to enter upon the CONSTRUCTION TAX
above-mentioned property for impeoion purposes. ALTER OR ADD TO MECH.
(We)ag m save,mdemnify and krep harMess rhe Ciry of Cupertino egvnrt
liabilities,' rnts,cons and expenses which moy�Ywry azcrveegeinn said Ciry AIR HANDLING UNIT
(TO 10,000 CFM)
v 1'the g^runfing ofpen. AIR HANDLING UNIT(OVER IO,Ogs CFM)
vv I v
tgnoure of Applicamu Coomaraor ✓ m EXHAUST HOOD(W/DUCI')
PAID
S RL•
HAZARDOUS MATERIALS DISCLOHEATING UNIT(TO 100.001)BTU) Data Receipt#
Will theapplicant or future buildingoccupantoate or handle hazemoos material HEATING UNIT(OVER W0.000 BTU) T
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(q? VENTILATION FAN(SINGLE RESIDE
❑Yes ❑No
ISSUANCE DATE
Will theappllcanmrfuturebui]ding occupant use equlptrtemordevi«ewhichemit BOILER-COMP(3HPOR I01000 BTU)
hazardous air contaminants as defined by the Buy Area Air Quality Management BOILER-COMP(OVER IW,WOBTU)
District?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. PAI
D
1 have read the haardous materials requirements under Chapter 6.95 of the 1'� g�
Celifomia Health&Safety Code,Sections 25505,25533 and 25534. I undereund tha
ifthe building dues not currently have amnam,that it is my responsibility m notify the FEB
mccupenf of the requirements which must be met prior to issuance of a Certificate of a/'19H//�G
Occupancy. CITY
Owner m authmixed agent Data TOTAL: ISSUED BY:
OFFICE