26708 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOI 1 -ELM MICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMRING.MECHANICAL 26708
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRES: (� - il SANITARY NO. APPLICATION SUBMHTAL DATE
10091 �P �J alp. , P-0 UNIT# LOT#
R AMB:\ yyOyE; CON'1'IMCfO�S NAME:I 1 n� LIC NO: N)C C TROL#"
'.ARCHITECf/ENGINEER: - ILTC[_N-IOM`:O- pS-'Sfll IW�1 ❑
CONTACT: PHONE: - BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE OO E
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
Ihercb B➢Di Natl 3 ofthe Business
er LOB DBBCRIpfJPr�
IY ❑y,� ya erovlslonsofamser9(commencing with pRr,T,
00 Section](100)of Division 3 of[he Business and Professions Cade,end my license is in PANELS
t az-. full force and eR
cM Lice a lass _ Lic.# UP T0200 AMPS
o "t Dale Contractor 201-1000 AMPS
Z FO Ut 7 ARCHITECTS D TION OVER 1000 AMPB SQ.FT.FLOOR AREA- .$/SQ.FT.
a.OZ-0 1 understand my plans shall be used as public records.
P is,g�� IaSIGNS MECTRICAL
g C ER
ctnsed Pro[wslonal
C OWN -BUILDERD ECLARATION SPECIAL CIRCUIT/MISC
yX00.E I hereby affirm that I em exempt from the Contractors a License Law for the
W 3 LLfollowing reason(Sermon construct,
Business and Professions Code:Any city err county TEMP.METER OR POLE INST.
1!101 rn which requires ea permit to Itth alma improve,demolish,fie a sig any swment
NY0 pnoressissuance.pursuant
to the
thevisio softhe Co permittosigned statement POWER DEVICES
µ) O p that he is licensed with
Section
the provisions of thethe Bu re's License Lew(shaper
0.{LOC or that nets exempt pt terfromandthe Division 3ofthe Business add professions Cade) SWIMMING POOL ELECTRIC VALUATION
W^Roe Sectiohaisexbyim,therefrom and the bamisfor the alleged exemptt to civil
of OUTLETS-SWITCHES-FIXTURES
no,me than by hundred
do][ ($50mrit subjeme the applicant to ecivil penalty of
nor more then Eva hundred dollars($500). NEW RESIDENTIALELECTR 5 FT.
❑runs,work,
addepruneny,ormyempindedco thwages asthei(Sol,compensation. Q' STORIES TYPE CONSTRUCTION
y will dothewons ande The ontranotinendede Law
not apply
and Professions Cade:The Contractors License Lew does not apply lf an owner of "
propertywyees,pdsorimpmveuch improve who acessuchwderforu eerad Inside.If,
ownhowempbyebuildi goyim rove ant iss sold
witsarenot intendedmpletiod fsaow.If, OCC.GROUP RES.UNITS
builder ,ill have the or improvement ofpmvi isshin he id none t build or improefim towner- TOTAL: '
builder will have the burden of poving fiat he did not build or improve for purpose of
sale.).
e -
❑ 1,as owneroftheperany.amexclusively contracting with ticenaedcomplarersto QT' PLUMBING PERMIT FEE FLOOD ZONE APN
conswr the project(Sec.701 Business and Professions Code:)The Contractor's
License Low does not apply to an owner effrontery who builds or improves thereon,and PERMITISSUANCE
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDEqFS
W RY Y N
Owner Date DRAINS- OO ' N,p RECEIPT#
TIO
WORKMAN COMPENSATION DECLARAN L:-'('i;y`II
H TAX Y N
I hereby affinar that l have a certificate allotment to self-insure,or a cenificae of FIXTURPSL PER P V RECEIPT#
Workers'Compensation
Insurance
gma=Aliffied copy flameof(Sce.3800,tab C.)which t ^-. :\ /' RK PEE Y N
GAS-EA.
Policy#I#'TI1-1l 11[1 Il ll 1, ��� SYS 4011TLETS
- RECEIPT#
BUILDING DIVISION FEES
Company GAS-EA. STEM- ) PLAN ECK FEE
ertified copy Is hereby furnished.
CeniBed copy is filed with the city inspection division.
GREASE/IttgalaL.WASTIS INTERCEPTOR GME
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS PEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is forme hundred dollars($100) SEWER-SANITARY-STORM EA,200FT. ENERGY FEE
or less.)
I certify that in the performance mine work for which this permit is issued,)shall WATER HEATER W/VENT/ELECfR
not employ any person in nny manner so as to become subject to the Workers' PAID
Compensation Laws of Califomia. Date WATER SYSTEM/TREATINGDam Receipt#
Z Afflicted
z� 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
Cnbecome subject to the Workers Compensation provisions of the Labor Cade,you must
�. , forthwith comply with such provisions or this permit shall he deemed revoked. BUILDING FEE
aA CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Z I hereby affirm that the.is a enumeration lending agency for the ptrformence of :
U Q the work for which this permit is issued(Sec 3097,Civ.C.) TOTALELECTRIC FEE
LL Lender's Name
U Ltnders Address QTY. MECHANICAL PERMIT FEE PLUMBING PEE
I certify that 1 have read this application and state that the above information is
correct.l agree to comply with all city and county ordinances and rale laws relating to PERMIT ISSUANCE MECHANICAL FEE
�^ to building construction,and hereby amhodu representativesofthis city to enter upon fie CONSTRUCTION TAX
U Z above-mentioned popery .for inspection Pact ALTER OR ADD TO MECH.
11+ (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilitice,judgmems,costs and expenses which may many way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
e uence of the graining of Nis noir.
1 /'1 AIR HANDLING UNIT(OVER I0,000 CFM)
St r of Applicant/Cisdowur 'Dide EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I Wp00 BTU) Date Receipt#
Will the applicant or future building occupant store or handle hazardous material
es defined by the Cupertino Municipal Code,Chapter 9.12,end the Health and Safety HEATING UNIT(OVER 100,00)BTU)
Code,Section 25532(a)?
13 yes, 11 No VENTILATION PAN(SINGLE RESID)
Will the applicantorfuwrebuildingoecopant ueeequipmenrordevices whichemit BOILER-COMP GHP OR UQ000 BTU) ISSUANCE DATE
s
hatemous air mneminwts as dented by the Bay Area Air Quality Management BOILER-COMP(OVER 100,00)BTU) PAID
District? '
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.IT.
1 have read the hazardous Sections 5505,25533 ostler Chapter understood
of the OCT 261994 ,rye
California Health&eSafetyhoz Code,Sections 25505,requirements
and 25534.I understand that
ifthe building does not currently have a tenant,that it is my responsibiiiiy to notify the /s
occupied of the requirements which must N met prior to issuance of a Certificate of CITY Ur
Community. ,.
Owner or authmiud agent - Dae TOTAL: ISSUEDBY:
OFFICE