26615 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PERMIT No.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIV I ION BUILDING PROJECT'IDENTIFICATION 26615
BUILDING ADDRESS: I, �g�'wa SANITARY NO. APPLICATIONSUBMIITALDATE
W`�V nt..V UNIT# LOT 6,
NS Ljsg..y
OWNAME: PHONE: CONTRACTOR'S NAME: LIC NO:P N/C CONTROL#t. c Lots,
•ARCHI CT/ENGINEER: LIC NO: ADDS
CONTACT: PHONE: 6(' 3 �•� C1-I5O9 OI F-1
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE � ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Matz Ihereby affirm that l am licensed under provisions of Chapter 9(commencing with
F 00 Section]000)of Division 3 of the Business and Professions Code,and my license is in pgy(pj-g
W,u fellforceCl...d,flan.
<UV fell focClLic.p Sa Y I UP TO 2110 AMPS
W
v8nK nate Contractor 201-RIW AMPS ws
C)Z i ARCHITECTS DECLARATION OVER IOW AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O Z'-'E 1 understand my plans shell be used as public records. ,
F y�, SIGNS ELECTRICAL
q Licensed Professional
LaWV OWNER-BUILDER DECLARATION SPECIAL CIRCUFGMISC.
Px;Oa 1 hereby affirm thaam exempt I aexempt from[he Contractors License Law far the
W 3 tc v following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLb4INS
which requires a permit to construct,aper,improve,demolish,or repair any structure �VVy
�'>•� I
PH.,to its issuance,also requires the applicant for such pennino file a signed statement POWER DEVICES
t tyyO0 that he is licensed pursuant to the Provisions of the Contractor's License Law(Chapter
IaXeu�. 9(commencing with Sectlmn]OIXI)of Divieion3ofthe Buxiness and Rvfeesimns Code) SWIMhDNO POOL ELECTRIC I VALUATION
ul-m
or that he is exempt therefmmand the basis for the alleged exemption.Any violation of S FIXTU
I-. a Section]031.5 by any applicant for a cermit subjects the applicant to,a civil Penalty of OUTLETS-SWITCH E
^� rot more than five hundred dollars($500).
W m ❑ EL S
nI,asowmrofthepmp"Y.armyemployeeswithwagesvtheirsolecompensadRESIDENTIAL
an. NEW RE$IDB �_ _ _ STORIES TYPE CONSTRUCTION
o, will do the work,amd the stochm,himtintended oroffered forsale(Sec.7044,Business -
and Professions Cade:The Contractor's License Law does not apply to an owner of
property w ho builds.,improves thereon,and who does such work himsel f or through his
own employees,provided that such improvements are not intended or offered for safe.It, OCC.GROUP RES.UNITS
however,the building or improvement is sold withinoneyearefcompletion,the owner- TOTAL:
builder will have the burden mproving that he did not build or improve for purpose of
sale.).
❑ I,as ownerofthe property,amexclusively contacting with licensed contractors to QTY' PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Seo.7044,Business and professions Code:)The Contracmrs
License Lew does not apply to an owner of property who builds or improves thereon,and PERMIT ISSUANCE
whocentracts for such projects with a contractor(s)licensed puramntto the Contractor, ALM EA FEF,SUMMARY
License Law. ( )
❑ 1 am exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE UTSIDE FEES
SANITARY YN
Owner Dare DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT'#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
1:1Ihaebyafiirm.,t l have a certificate ofeonsent to self-i ns.re,ora certificate of FIXTURES THAT
RECEIPT'#
Workers'Compensation Insurance nr nnertifedcopy thereof(Sec.38W,Leb CJwhich PARK FEE YN
coven all employee's under his permit. GAS-EA.SYSTEM-1 INC. OUTLET RECEIPT#
Policy# BUILDING DIVISION FEES
Company
[2 CerOfied copy is hereby tumiehed. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not becompleted ifthecermit is forma,hundred dwimsf$1W) SEWER-SANITARY-STORM EA.20fFT. ENERGY FEE
or less.)
I certify that in the performance of the work for which this Permit is issued,I shall WATER HEATER W/VENT/LLECTR
Hot employ any person in any manner so as to become subject to the Workers PAID
Compensation Lawsof C.lifamie. Date WATER SYSTEM/IREATING Date Receiptp
Q z Applicant
R NOTICE TO APPLICANT:If,after making this Certlficare of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. ET become subject to the Workers Compensation provisions of the Labor Code,you most
forthwith comply with such provisions or this permit shall he deemed revoked. BUILDING FEE
JIG C(
W z CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihereby affimt that there is a construction lending agency for the performance of
JK
U O the work for which this permit is issued(Sec.3097,Civ.CJ TOTAL: ELECTRIC FE
LIy P Lender's Name
0 U Under'a Address QTY. MECHANICAL PERMIT FEE PLUMBING fAS
W 1 certify that I have read this application and state that the above information is
coerecMECH L 'EE
t:I agree to comply with of city and county ordinances and state laws relating to PERMIT ISSUANCE
rjj building construction,and hereby audience representatives ofthiscity to cou,U,gam the CONS ON TAX
U 7 above-mentioned pmpeny for inspection purposes. ALTER OR ADD TO SUCH.F7 (We)agree to save,indemnify and keep harmless the City of CLpsoino against
'na ov es,jm menta,costsandexpenseswhichmay Tnanywayac teagainstsaid City AIRHANDLINGUNIT(TOIO,WOCFM)
ran gran[i of this per 1.
AIR HANDLMG UNIT(OVER 10,W0 CFM)
S' at ofA�ppficl& Cnotmcuar 40 6 Da¢ EXHAUST HOOD(W/DUCf) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT TO 1W,000 BTU) Date Receipt It
ill the applicant or future building occupant store or handle hamrdous mamn.l HEATING UNIT(OVER 100,001)BTU) T
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)?
❑Yes 13 NO VENTILATION PAN(SINGLE RESID)
Will thea applicant building occupants,, ui BOILER-COMP(3HP OR 1W,00)BTU)
ISSUA E DATE
pp gheequipment Quality
Management hamic,? air contaminants as defined by the Bay Areu Air Quality Management BOILER-COMP(OVER 1W,0W BTU)
District? '
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. q>, 11 D
1 have read the hasfeta Cede.
materiels requirements under Chapter understand
of the 7f' IY� j
if the building
do&Safety Code,Sections 25505,25533 it
and 25534.I understand the �( .T„'••_
ifof dnequirem currently which
mustve a be that ii is my responsibility of a Ce notify the
occupant an o[the requirements which must be met prior to issuance of a Certificate of J
Occupancy.
Owner or authorized agent Dam TOTAL: ISSUED BY:
OFFICE