26130 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUILDING-F.LuCI KI AL - PERMIT NO.
CITY OF CUPERTINO PLUMBING-MECHANICALC' 26130
BUILDING.DIVISION APPLICATION/PERMIT
BUILDING PRUJE1'IDENTIFICATION
2U-ILD CS•9E S: � - SANITARY NO. APPLICATIONSUBMITPALDATE
/oG. 1 UNIT# LOT# "'25-4e
O ERS NA //` PH CO RACTOR'SNAME' LIG NO:
W / NIC CONTROL
XRCIIITECUENGINEER: LIC O: A R S: ❑
_L CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PI MB MECH
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESC UPH N
Q y.2 I hweby aKrmthat I am licensed unduproviaionsof Chapmr9(wmmencing wish
1x100 Section 9000).(Division 3 ofthe Businas's and Professions Code,and my license is in PANELS
yFFy� CCCC full force and effect. /'�
<Z, License Clan Lia# 2 /d'!/ UP TO 200 AMPS
o<d Date n C.ntmc r 201-I"AMPS
Z.Ou'Z CHITECPS DECLARATION OVER 1000 AMPS SQ.FP.FLOOR AREA $/SQ.FT.
OZ'-O I decstand "Itenshallbeus blic 2oN
roe�dta� 1 oe tx-,A T� 1/ SIGNS ELECTRICAL pII IIT-''�'
ys < OWNER-BUILDER DFDLARATIOI SPECIAL CIRCUIT/MISC. s Lam, h ® IN
OiU I hereby affirm that 1 am exempt from the Corrector's License Law for the - p p
W u.y followingreason.(Section7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST. v � �� � II II E
which requires a pemtir m consrmct,cher,improve,demMish,nr repair any structure _ `�J'
prior,.its issuamcaelmosPirestheapplicant for suchpermiuo fileasigned statement POWER DEVICES
[U <p that he is licensed pursuant m the provisions ofthe Contractor's License Law(Chapter
o.go�1 3 lig 04
9(commencing with Section 90007 of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC FATION
ipl,-y or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLEfS-SWITCHES-FlXTURES
CSection 7031.5 by any applicant for a panic subjects the applicant to a civil Penalty.(
Out more than five hundred dollars($500).
❑ I,asownerofthepropeny,ormyemployeeswiNwagesas,heirsolecompensa,ion, NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
pW„3� will do thework,and the swcmreis not mcmdedmuffered mrsale(Ser.TEM,Business
and Professions Cade:The Contractor's License Law does not apply to an owner of
propertywho buildsorimposes therescand who does such work himselforthrough his OCC.GROUP RES.UNITS
ownemployees,provided thatsuch improvememsare no,intendedorofferod forsale.If, '
however,the buildingor improvement is sold within one yesrofcompletion,the owner-
builder will have the burden m' nt ,ha he did not build or int for f TOTAL:
prov' g prove purpose.
seta.).
❑ i,as owner ofthe property,am exclusively contracting with licensedc.nuanors to QTY. PLUMBING PERMIT FEE FLOOD ZONE, APN
construct the project(Sec.7044,Business and Professions Code:)'The Contractor's
License Lawdoesnotapply loan ownerofpropeny,adobuilds orimproves thereon,and
PERMIT ISSUANCE, -
whocontrec,s for such projects with a conlzecor(s)licensed pursuant to the Commences W
ER
L
gT -DRAIN&VENT- ATER BA
License Lew. (EAT FEESUMMARY
❑ 1 em exempt under Sec. ,B&P C for this reason BACK 41000 PROTECT,DEVICE OUTSIDE FEES
SANITARY Y N
Owner Date DRAINS-FLOOR.BOOK AREA,COND. - RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Iherebyaffinnthat l have a cenificate ofconsen,to self-mance,or a Certificate of FlXTl1RE5-PER TRAP RECEIPT#
Workers Compensation Insurance or a certified copy thereof(See.3800,Lab C.)which PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cenlfied copy is hereby fumished.
❑ Certified copy is filed with the city inspection division. GREASEANDUSTRI.WASTE INTERCEPTOR GRADING FEE
I
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section needror be completed iftho permit is formes hundreddollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or las.)
I certify that in the performance ofthe work for which this permit is issued,I shall WATER HEATER W/VENT/ELELTR
no,employ any person in any manner so as in become subject to the Workers' PAID
Compensation Lawsof Celifomio. Date WATER SYSTEM(TREATING Date Receipt#
O ,Z Applicator
Z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ. TOTAL:
became subject to the Worker's Compensation provisions ofthe Labor Code,you must
forthwith comply with such provisions or this Permit shall be deemed revoked. BUILDING FEE
LLI (] CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that hem is u construction lending agency for the performance of
U O the work for which this Permit is issued(Sec.3097,Civ.C.) T ELECTRIC FEE
Lender's Nauta
C) F Lender a Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U I certify that I have read this application and state that the above information is
cortemlagreetocomplywithalleityinle...ty ordinances and stole lawsrelating to PERMIT ISSUANCE. MECHANICAL PEE
buddingeonstruction,andhereby authorise representatives ofthiseity to enter upon the
CONSTRUCTIONTAX
C) z above-merioned pro toy for inspection puryoses. ALTERORADDTOMECIL
(We)agree ,indicant and keep h ss the City of Cu echno against _
liabilities,jud ms,cossand exhly sea sea yinany we ac inst aei ity AIR HANDLING UNIT(TO 10,01))CFM)
usequ ofrhegmntingofthis pe
AIR HANDLING UNIT(OVER 10,000 CFM)
S' ore pelican nnwdor toI EXHAUST HOOD(W/DUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 108000 BTU) Date Receipt#
Willthe applicant or farure building occupant time or handle hazardous material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cafe,Section 25532(a)Y
❑Yes ❑N. VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
Will he applicant calcium building oecupanmseegoipmenmrdevices which emit BOILER-COME(3HP OR 100,000 BTU)
hazardous air connotations as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,00)BTU) p p, B D
Disu cf!
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have read the hazardous mations requirements under Chapter erste of the HEAR"'eall
Culifn ha a read t Safety Code,Sections 25505,ement and 25534. IunderstandZhao flflifthe building does no,currently have a tenant,that it is my responsibility to notify the
occupant of the requirements which must be met prior to issuance of a Certificate of 7-Uru
Occupancy. /�✓'"]
Owner or authorized agem Date TOTAL: ISSUED BY:
OFFICE