26605 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ."Mi=ELECTRICA PHRMITNO.
APPLICATION/PERMIT PLUMBIN G-MECHANICAL [A Q O C
BUILDING DIVISION BUILDING PROJECv
T IDENTIFICATION v J
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAIS
UNIT# LOT# 1�
OWNI?R'NAME: PHONE CO ACTOR'S NAME: LIC NO: /
_ N/C CA RUL#
AliClil'I'h:CT/FNGINEIIk: LIC NO: L AD RIiSS:LD p
NA0
CONTACT: PHONE: v BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT' FEE
/ BLDG ELECT LUMR MECH
3 PERMIT ISSUANCE El
LICENSED CONTRACTOR'S DECL. RATION APPLIANCES-RESIDENTIAL -JOB DESCRIPTION
pyy Iherebyaffirmlhi am licensed under provisions aider commend th
IvlOp Scdinn]OW)of Division 3ofthe Business and Profen.ons Cod and mylic PANELS
FqFq-' f❑; full forwnnd affec /� UP TO 20)AMPS
QF Z yl License Class IO Liu,# sin
m7N IlnteContractor ✓ 201-1000 AMPS
ZOsoz ARCHI'IECPSDEC TIOQ. . 1,0 v IT.
�.
lundemandm 1 M1ll be used as abide records. OVER IBM AMPS r
OZ,
I:.Yh; SIGNS PlECRtICAL \ ;• I--� 11 T L^_' 1�1
Q F licensed F'rofessionat 10�� flll.' I T-Ci
i�I�+IU
OWNERBUILDERDECLARATION SPECIAL CIRCIIIT/MISC, t L V'
K OIyF I hereby affirm that 1 ma'
m exempt from the Contractor's License Law for the
Wwarn following reason.(Section]031.5,Husiness and Professions Code:Any city or county TEMP.METER OR POLE INST. DATE
Yr
ES whicM1 reyuircs a pennil ro cnnwrvn,eller,improve,Jemnlish,ter repair any ewcture
N� prior to its Issuance,also ruryires the applicant forsueh Permit o lila a signed statement POWER DEVICES
µ1p0 Prot he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
n p�' 9(commencing with Section 7000)of Division 3 ofthe Business and Professions Code) - SWIMMINGPOOLELECI'RIC VALUATION
'µ s, or he is exempt therefrom and the basisfor the at leged exemption.Any violation of 'OUTLETS-SWITCHES-TEXTURES
Z Q Section 7031.5 by any applicant fora pewit subjects the applicam ty,to a civil para of
C act mom than rose hundred dollars HOW).
C m ❑ I,asownerofthepropeny,ormyemployeeswithaagamtheirsolecompensadon, NCWRPSIDEMTALELECIR _SQ.FT. SIY1RIIiS TYPECONSR CION
i3_ will do the work,and the structure is not intended croRered for sale(Sm.]044,Business
and Prefci ns Cale:The Contractor's License Law does not apply to an owner of
propertywhobuildsorimproves thro a Land whodcea inch work himselforthraughhis
on entpl,ma,provided that such imm
proveentsare not intended oroffered(orange.if, - OCOGROUP RCS UNI'T'S
however,the building or improvement is add within one yearofcompletion,the owner- TOTAL:
builder will have the burden of provingmathedldnom
r build orimpveforpetpamof - -
su1e.).
❑ I,as.wnerof the prnpeny,am ezdosivdycontrading withlicenud eommcmrsm QTY. PLUMBING PERMIT FET? FLOOD ZONIi APN
construct the project(Sec.]044,Business and Professions Cale:)The Contractors Li cense"seduction apply loan owner o f property w h o bu i Ida or improves i hereon,and PERMIT ISSUANCE
who canwcts forsuch projects with aconaactogs)licensed pursuant to the Conuacmrs
License Law. ALTER-DRAIN&VENT-WATER(PA) RiE SUMMARY
❑ I em exempt antler Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE I SIDE FEES
SANITARY Y N
Owner - Data RECEIPT
CHAINS-FLOORROOF,ARBA,COND.
f WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ Thereby affirm thatllinventtnifcate nl consenun sdl'-in sure,oracenifcateol' RECEIPT If
FIXTURES-PER
Work.Compensation Insurance ora candied copy thereof(Sec.3g011,LabCJ which - PARK FEF. Y N
covers.11 employee's under this pewit. GAS-EA.SV51TiM-I INCA(IUTLEfS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVHR4 G!A) PLANCHECK IEE
C3nified copy is hereby famished.
''citified copy is fled with the city inspection division. GREASEIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP SOILS FEE
COMPFNSAI'[ON INSURANCE
('Ibis section need not Is,completed afire permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
car less.)
I ardythat India ped oman nce of the work for which this pewit is issued,i shall WATER HEATER W/VENT/IiI.ECTR
nm employ any person in any m m
s o to become subject to the Workers PAID
Compensation laws.(Cdi(nmie. DoeWATER SYSTEbVfRG- I"INC Data Neoeiptp
Applicant
�.Q NOUCE TO APPLICANT:If,after making this Certificate of Exemption, TOTAL:
z g p you should NEW RESIDENTIAL PLMR. SQ. T.
become subject o the Worker's Compensation provisions ofihe labor Cade,you must -
7 forthwith comply with such Provisions orthis pcwitshallhd«mMtnvoked. BUILDING ME
OW. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Uz 1 hereby affirm that then is a construction lending agency for the performance of _
O, the work for which this pe.it is issued(Sea 3097,Civ.C.) TOTAL: ELECTRIC FT Ii
L>ti Tondos Name - FEE PLUMBING FEE
U I,endet's Address - QTY. MIsCHANICAI.PIiRMIT' hEF.
I certify that I have read this application and state that the above information is
correct.) to comply with all cit and count ordinances and state lows retailing to PERMIT ISSUANCE MECHANICAL FEF.
agree manYwi Y se 8
E-' building co swction, dhemby ambo' prtsentadv<sof thirtiry to enter upon the CONSTRUCTIONTAX
U z above-me ionedf
ny far inspeci n m,rses. ALTER OR ADD TO MECH.
(W agree e,indemnify and ep hawlas the City of Cupertino against
l iabilitiejudgmebandex hichmay in my way acerueagainst said City AIR HANDLING UNIT('1010,000 CFM)
1.
in cit se vent oranting of wit.
n
AIR HANDLING UNIT(OVER 10,000 CPM)
JA
Sign.to of p cool/lona t - 15. HXHAUSTHOOU(W/DUCT) PAID
HAZARDOUS MATFRIALS DISCLOSURE IIHA'I']NO UNIT(TO 10,000 OTU) Data keceipt#
Will the applicant or future building occupant same or handle hazallous material IIIeA'I'ING UNIT(OVER I 00,00D BTU) TOTAL:
as defined by the Calendar.Municipal Code,Chapter 9.12,and the Health and Safety
GNe,Section 25532(e)?
0Yes 1:1 No VENTILATION FAN(SINGLE RISHU
Will the applicant or Boum building occupant use equipment or device which emit
BOILER-CONiP UHP OR 109,000 BTU) ISSUANCE DATE
harardous at commitments as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District?
Y. 0 N - NEW RESIDENTIAL MFCI1. SQ.FT.
I bas read ere zardo,,red, regairememts and
CM1apter 6.95.f the 01994
Culifomie sell&S ey Code,Senir 23505.25533 and 25334. I understand that
occupad ng it curentlyhuve mart.that it is my responsibility to notify the �n
a:cup n f the u'ememx which t us M met prior m issuance of a Cmif ate of u s t Uyx
Oscal m �✓
Owner. archon gem sDsa TOTAL: ISSUED
OFFICE