26213 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOUUII.V[N(;-LLEU FRICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 26213
BUILDINGAWVESS: SANITARY NO. APPLICATIONSUBMITTALDATI
03 UNI'TN LOTH �Gjf�
,�-VNE N^ ^�" c PHONE: _ CONTRA 'ORYNAME: (% LIC NO:� ^�
Y !+ V NIC CONTROL It
'Rulil IF.CI'/F:NGINEER: LIC NO: ADDRESS,,N J4 1 ^�� S� ❑
CONTACT: PHONE: /u s\l BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
OTGZ I hereby iflimrthat l am licensed toulm,rovisions of Chapler9(commencing with J08 DESCRIPTION
J400 Section TWO)of Division 3 of the BusinessdPmfcssi Code.and my license is in PANELS
<ZW- full force and eff /^ 2 R�� IIP TO 20B AMPS � II�N}dq.iV
, LicenseClaas,�Lie.N 03 l
y« C Contractor 201-1Wfi AMPS
FOm ARCHITECTS DECLARATION OVER IOfiOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
O Z_ 1 unJemm�J my plans shall be used m public records.
P vc F W SIGNS ELECTRICAL
Y�.,...II Liccnwd Professional
y.C¢ OWNER-BUILDER DECLARATION SPECIALCIRCUYDMISC.
Oo.Fu- I hereby affirm that I am exempt from the Contractor's License Law for the
w 3 0 to fol lowing reason.(Section 7031.5.Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
which requite a permit m construct,aheq improve,demolish,m repair,any atrvctwe
tvmtv�}� prior to its ixsuunce,also requires the applicant for such permit to file a signed statement POWER DEVICES
C 00 that he is licensed pursuant m the provisions of the Coronaries License Low(Chapter,
aX 9(enmmcneirg with Section 7")of Division 3 of the Businessand Rafessions Code) CUSH: VALUATION SWIMMING POOL ELE
or that he is exempt and the basis for the alleged exemption.Any violation of
1-.Z} Section 7031.5 by any application for.permit subjects the applicannOUTLETS o a civil penalty of SWITCHFS-
FIXTURES
EE< m more than five hundred dollar,($5W). NEW RESIDENTIAL ELECfR 5 .FT. �g(�pR'/FFFSSS
C F_o n❑ Lasownerofthe PropenY�ormYcmplmym wiNwaBcsastheirsole<ompcmadon, Q V/ TYPE CONSTRUCTIOD
y3= will do the work,and the stmcturc isnot imendW oroffercd forsale(See.70J4,Business /
and Professions Ctdc: fla,Contractor's License Law does not apply to an owner of
propcnywhobuildsorimprovesthcre =dwhodoessuchwmkhitmclfmthrough Na
own employees,pravidedthat such improvcmemsare not imendeduroffered forsale.If. OCC.GR U RES.UNITS
howevegthe buildingor improvement is sold within one yearofcompletion,the owner- ,I, r�
builder will have the burden of proving that he did not build or improve for puryoac of
sale.).
❑ Lace owner ofthe property,am exclusivelycommetingwith licensed contractors m QTY. PLUMBING PERMIT FEE FLOOD ZONE ppN
construct the project(Sec,7044,Business and Professions Code:)The Conuumra
License Law does not apply toanownamdpropeny whobuilds or improves thereon,and PERMIT ISSUANCE
who currants frrauch projects with acomractons)licensed pursuant m the Commcmrs ALTER FA
License Law. O FEE SUMMARY
❑ I am exempt under S<n. ,B&P C Tor this reason BACK FLOW PROTECT.DEVICE ONSIDE FEES
SANITARY YN
Owner Dat° DRAINS-FLOOR.ROOF,AREA,COND. RF.CEIPfN
WORKMAN COMPENSATION ONDECLARATION SCHOOL TAX Y N_
❑ em Co uffirationI Insurance
ora ceneof copydumof(Sanowto s.re,or Lab C.))whichate of TEXT'URES-PER'rRAP RECEIPT#
orkers Compensation lnvurancc oracenifiedcopy thertof(Sec.3gW,Lab C.)which PARK FEE YN
colics all employee's undcnhis permit. GAS-EA.SYS3LM.I INC.4 OUTLETS RECIiI1T N
Policy N BUILDING DIVISION MES
Company GAS-G.SYSTEM-OVER (EA)❑ Ccnified copy is hereby famished. ( PLANCHF,CK FEF,
❑ Certified copy is filed with the city impaction division. GREASMNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKP.RY GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section cad not he completed ifthe permit is foronchundtd dollmrs($IW) SEWER-SANITARY-STORM EA.2WIT. ENERGY FEE
in lcsr.)
I certify that in the performance ofthe work for which this permit is isaud.I rhall WATER HEATER W/VENT/ELECTR
not employ any person in any mar arT so as to become subject to the Workers PAID
Z Crmpensntion Lawxuf Califomia. Data WATER SYSTEM/I'REATING Date Receipt If
Applicant
� Q NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.Fr. TOTAL:
f-' 4 become subject the Worker's Compensation provisions of the Labor Code,you must
forthwith comply with such Provisions or this permit shall be deemd revoked.
ul F BUILDING FHfi
0. F)
CONSTRUCTION LENDINGAGENCY SEISMIC FEE
I hereby affirm that the.is a contraction lending agency for the pert nummoo of
V O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEF.
I.edces Name
ULeaders Addre.a Q'LY. MECHANICAL PERMIT FEE PLUMBING FEE
I certify that 1 have Iced this application and state that the above information is
counter. l agree to comply with a0 city and county ordinances and.state laws relating to PERMIT ISSUANCE MECHANICAL FEE
F^ DO building construction.and hereby authorize representatives ofthiscity memeropomhe
U Z above-memlomd propeny for inspection pugnsca. ALTER OR ADD TO MECH. CONSTRUCTIONTAX
(We)agree m save,indemnify and keep humorless the City of Cupertino against
liabilities,' Jgmema,costs andexpcnss which may inany way accomagaimst said City AIR HANDLING UNIT(TO 10,OW CFM)
in c ase ince of th�yrdyyng of this permit. —
�� AIR HANDLING UNIT(OVER 10,000 CFM)
'001gnature of App imr.VCommc Dtlte EXHAUSTHOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,M)BTU) D;me R
Will the applicam or future building tntup.[stere or handle hazardous manerid
as cleaned by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety ItFTING UNIT(OVER IM."BTU)
Code,Section 25532(a)p
❑Yes 0N VENTILATION FAN(SINGLE RESID)
Will the vppliwm nr[uwrc building oecupwt use cquipmem art devices which emit
HOBER-COMP(314P OR 100,0010 BTU) ISSUANCE DATE
h..daus air contaminants u defined by the Bay Area Air Quality Management BOILER-
COMP(OVER I W,IXM]BTU)
❑Yes ❑No NEW RESIDENTIAL MECH.
I have rend the hvardous malcnals requirements under Chapter 6.95 of the PA / D
if he building
ing lthdo A set etycur Codeamly Sections 25505,25533 it
1 r 25534. I understand that
ifuproldinge requaemmendy have allbm,that is myrtsponsiofa Cto arnmify the QR a.o
(ac upas of the requirtmend whish must be met prior m issuance of n CcniOnem of n VY
Xa.panny. 9
Owner or autbnree l agent Dane CII
TOTAL: ISSUED HYr V Ur
OFFIC