26744 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 11 ILUING-LILL I RICAIPERMITNO.
PLUMBING MECHANICAL BUILDING DIVISION APPLICATION/PERMIT BUILDING PROJECTY IDENTIFICATION
26744
BUILDING
ADDRESS: N. (/)]�/\ SANITARYNO. APPLICATION SUaH/MITI'AI.TIATH
1010L O P L �� N�.� \INIT" LOTH
O A PHONE: CONTRACTOR'S NAME: LIC NO: l
NC COMROLN
`,RCHI'rECT/INGINEER: LICNO, ADDRESS:
CON'I'ACI': PHONE: BUILDING PERMIT INFO
QTY. HLECTRIC PERMIT FEE
APLUMP MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
y,2 1 hereby off.that 1 am licensed underprnviaions ofchapter9(commencing with
�00 Section 7000)of Division 3.[the Business and Professions Cade,and my license n vn PANELS
y�11— full
]If me and affect.
F<Zw License hic.N UYT0200 AMPS
yQa Dam Coneacmr a 201-I"AMPS
1—,,„j ARCHITEM" O OVER 1000 AMPS SQ.FF.FLOOR AREA $/SQ,IT.
zouo - 1 understand my plans Shull he.sal u% blit re...da.
OZ—F u=i SIGNS ELECTRICAL
Z�EJ Licensed Professional
25926 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
o'OaU 1 hereby affirm that 1 am exempt form the Contractors License Law for the
LL3LLy fallowing ream".(Section 703 L5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
which requires a pdomil In construct,:Ater,improve,demolish,or repair any structure
W}7 pHot to its issaereprisesnce,alsa reprises the applicant for such permit file a signed statement POWER DEVICES
,ceG that he is licensed particular o the provisions of the Condolences License law(Chapror
tiu,o�' 9fcnntmencingwith Seel on 70k))of Division 3 or the Business and Profession%Godo) SWIMMING POOL ELECTRIC VALUATION
W_y or that he is exempt herefrom and the hams for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURIS I� W'
FZa Section 7031.5 by any applicant for a permit subject the applicant o a civil penalty of is
�'1p not snore Nan Eve hundred doll...H500q. NEW RESIDENTIAL ELECTR _SQ.FT. STORIES TYPE CONSTRUCTION
Xt. ❑ Laaow"emfthc propeaY.manyemployeeswith wages walocirsolecompe"saoon.
6'3� will Profession,
andtneEad CoreisnOtimendWerawdue,net a Sec.7Baa Business
and rrare%aimr.Cade:Ina a,mmadra hi«naa Law Ansa not apply m a"owner or
pal whobuildzor improves therma.snd,hrde,...ch work himselfm Nmil dahis OCC.GROUT' RFS.UNITS
own employees,provided Nat such improvements arc not intended or offered fm sola.If.
however,the building or improvement is sold within oneyearofcompletion,the owner. TOTAL
builder will have the burdenofprovingthus he did not buildorimprovefarpurpos of
'`'de')'
❑ I,nn owner of the pmpeny,am exclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEE ROOD ZONE AYN
onsmun the prejem(Sed.70x4,Business and Professions Code:)The Co macmr's
License Lawdoesnotapplytoanownerofpropenywhobuildsorimpmvesthert n,mal PERMIT ISSUANCE
who contracts la,,a,h porj«ta with.connacrob)liecowd puauum u,dracomracom,
Lid'.-law. ALTER-DRAIN&VENT-WATER(EA) ITE SUMMARY
❑ 1 am exempt under Sec. .B&P C for Nis reasonOUTSIDE FlI
ff-
BACK FLOW PR T .DEVICE. SANITARY V N
Owner Date DRAINS-FT, ,R '. EEACOND. RIECHurt'N
WORKMAN COMPENSATION DECLARATION SCHOOL TA%, YN
❑ lnemhyeffrmthmlhaveacenilicicofntnsenitoself-insure,oracurtificmenfPI%'NRES-PER TRAP RECEIPT'
Jf-
Worker:Compe"mtion Insurance or a candied copy theelf(Sce.3800,1ab CJwhich PARK FEE Y N
RECE 1'M
%.Vere all employee's under Nis pcmtit.QCP. 39007fe� GAS-EA.SYSTEMd{CI�OIT BUILDINGE SIGN FEES
Company— p S/� r �'1W 71
GAS-EA.SYSTEM-O 0 ) PLANCHECK FEE
❑ Certified copy is hereby furni
flialeCeniried copy is had with the city inspeadon division. GREASMNDUS' ASTE 11 ,41,'EYT R GRADING FEC
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETR S SOILS FEE
COMPENSATION INSURANCE
(This season random becompined if Ne permit is forone hundred dollars($lip) SEWER-SANITARY-S MEA.2WP1'. ENP GY FEE
or less.)
I cenify that in the perfomansecot the work for which is permit is issued,lshall WATER HEATER T/EL.
nm employ,any pared"in any manner so a to a subjm to the Workers' PAI
Compensation Laws of California
Data WATER SYSTEMi'M TI G 1 m R«st,#
zZ Applicant
0 NOTICE TO APPLICANT:ILafmt making thts nift m fEaemption,you should NEW RESIDENTIAL PLMB. SQ. TOTAL:
7) become subject m the Wmka's Compensaion p v s ons of the Labor Code,you must B L FEE �•
a � forthwith comply with such previsions or this omit shall be deemed revoked.
(� CONSTRUCTION LENDING AGENCY SEI BE
"IZ Ihereby affirm that hereis a comouction lending agency for the a,damance of TOTAL; ELBE 'FEE
U O the work for which this pemtit is issued(See Civ.CJ
Linda,,Name 3 . p ME
0 F Lender.Address QTY. MECHANICAL PERMIT FEE
Q U 1 cenify that I have mad this a r c nt mm that the above information is ML AL FEE
enrmt.I.,,a.tocumply withal)city anaceumy ordinances and state laws relating to PERMIT ISSUANCE
F" buildingeonstruclion,and hereby author a representatives ofthis city toenmr upon the CONSTRUCTION TAX
U z aborome timed proarty for inspection purposes ALTER OR ADD TO MECH.
(We)agree to.save,indemnify and keep harmless the City of Cupertino against
Iiabiliiies,judgments.costs and expenses which may to any way accrue against said City AIR HANDLING UNIT IT 010,003 CFM)
in consequence of the granling of this permit.
AIR HANDLING UNIT(OVER 10,000 ChM)
Signature of Applicant/Cmdrvcmr Data EXHAUST HOOD OVIDUCT) PAID
IIALARDOUS MATERIALS DISCLOSURE I MATING UNIT(TO IW.WO BTU) pans R«ci p
QL
Will the applicant or future building eccupsnt store m handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9,12,and the Health and Safely I HEATING UNIT(OVER 100.000 BTU) y
Cmle,Seclinn 25532(.)^ VENTILATION PAN(SINGLE RPSID) LOW1
❑Yes X.
Will the uconcamna is aw building occupantuse equipmentmdevicewhichemit
BOILER-CORP(3HP OR 10y"BTU) ISSUANCE 1
hmardous air contaminants v defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
Dim,to?
Cl Yes � NEW RESIDENT[AL MECH. SQ.FT.
1 have read the hazardous materials requirements under Chapter 6.95 of the
California IIeuIN&Safety Code,Sections 25505.25533 and 25534. I understand that
if the M1uilding doe yl currently have a unant.dol it is my responsibility to notify the
oavpimt of N yi � ich must be met prim m issuance of a Cenificme of
Occupancy.
Owneror mh A g A -J fData TOTAL: ISSUED BY:
OFFI