26426 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING-ELECRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT
PLUMBINGROJECTFIDENTIFIC 26426
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS
� SANITARY NO. APPLICATIONSUBMITTALDATE
_6 7N NIT# LOT Is i.
OW NG TIME 8 PHONF�. - a, CONTRACTOR'S NAME LIC NO:
N/C CONTROL g
�ARCI TE /ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY, ELECTRIC PERMIT FEE
BLDG ELECT PLUMB M[CH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DESCRIPTION
GKZ Ihereby affirm Nat l am lianmd underpmvisionsofaapter9(co=m ngwiih
PJ00 Section 70(oh nrDivision Sof the Business and Prmessima Code.md my license is in PANELS
full farce and effect.
Gz W License Cles.s LICK UPT02WAMPS 4��♦
to Dale Convector 201-IOW AMPS
F yoe ARCHITECTS DECLARATIONSQ.FT.FLOOR AREA S/SQ.FT.
20vs� OVER TWO AMPS
10RIMM I understand my Dlarm shall be used ss public records.
^
� .WJ SIGNS ELECTRICAL
Q Q LicensedP Professional OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC. �
aX 0 V 1 hereby affirm that 1 sm exempt from the Common's License Law for the
m3uH following mason.Section 7031.5.Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
vo O which requires a Permit to construct,alter,improve,demolish,or mpa'u any structure
�Y� mitsissuance,ulso thea licantforsuch uofileasi edtrimmed, POWER DEVICES
thaprim requires PP perms gn
�O 9(che rsnvir,wpursction7the pmvisiadxaf the the Contractor's and PreLavv,.,ims spar SWIMMING POOL ELECTRIC
"at
exemith5ectiorn Wt he Division 3 o theed rat end ProfessionsCMe) VALUATION
_y mNn he is aempuhercfromand the basis for she alleged rat
OII'ILETS-SWITCHES-FlXTURES ��
¢�-+4
Section 7031,5 by any applicant for a Permit subjects the applicenuoacivil penalty of
t more then five hundred dollars($5W).
K 0 ❑ I,asownerofthcpmpeny.ormyemployceawiN wagesmtMinolecompmaation, NEW RESIDENTIAL ELECTR _SQ.PT. STORIES TYPECONSTRUCTION
a3� will do the work,and thestructure is not intendedoroffaed formic Sm. WA.1hsiness
and Professions Cade:The Convectors License Law does nae apply to m owner of
property whobtildsorimMoves themon,md whodoes such work himselfm through his QCCGqqq RES.UNITS
ownemployees.pmvidedthat such impmmarad tam notimeMedorofferedforsole.If. 7 ///
however,the building or improvement is sold withinone yearofcompletion,the owner- TOT L: �/I
builder will have the burden of proving that he did not build or improve for purpose of / I
sale.).
❑ I,ssowncrofthepropeny,nmexclusively eonveeeingwiNlie<nmd crno-eanrsm QTY. PLUMBING PERMIT FEE FLOODN APN
construct the project(Sec.7084,Business and Professors Code:)The Convector's
License Lew doesnot apply manownernfproPny whobmIdsmimprove,thereon,and PERMIT ISSUANCE
whocoracts for such Projects with a contmctn(s)licensed pursuant to the Contractors
License Law. IN ALTER-DRA &VENT-WATER(EA) FEE SUMMARY
OUTSIDE
❑ 1 am exempt under Sm. .B @ P C for Otis mason BACK FLOW PROTECT.DEVICE
SANITARY Y N
Owner Date DRAINS-1100R,ROOF.AREA,COND. RECEIPTM
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN_
❑ I hereby affirm that l have acenificateofconsenno self-insure,ma cenifmateof FIXTURES-PE.R TRAP RECEIPTa
Wark<re'Compenvtionlnsumrrcearacenified copy thereof(Sec.38W,Lab CJwhich PARK FIDE YN
covers all employed,under Nis permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT'to
Policyp BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-0VER 4(EA) PLANCHECK FEE
❑ Candied copy is hereby famished,
❑ Certified copy is filed with the city irlbpSeion division GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
COussection need not he completed ifthe Permit is forone hundred dollars($1W) SEWER-SANITARY-STORM EA.20aFT. ENERGY FEE
m less.)
I codify that in the Performance of the work for which this Permit is issued,l shall WATER HEATER W/VENT(:LECTR
not employ any passed in any manner sec as m become subject to Ne Workers PAID
Compensation Laws of California. Dam WATER SYSTEM/TREATING Date Receipt#
Z rot .
zOz�-I Z NOTICE TO APPLICANT':IL after making this CenificmNEW RESIDENTIAL PCMB.e of Exemption,you should SQ.FT. TOTAL:
t-' N become subject to the Worker's Compensation provisions of the Labor Code,you nun
Friforthwith comply with such provision m this Permit shell be deemed revoked. BUILDING EEE
DJ SEISMIC FEE
0. [a CONSTRUCTION LENDING AGENCY
1 herehy affirm tharthe.is a construction lending agency for the performance of
V Z the mark far which this Permit is ismed(Sec.3W],Civ.C.) TOTAL: ELECTRIC FEE
Lenders Name PLUMBING FEE
f-' Lender's Address QTY. MECHANICAL PERMIT FEE
L) 1 cenify that 1 have read this application and state that the above information is MECHANICAL FEE
r 0. cr act.l agree to comply with all city and county ordinances and sloe laws relating to PERMIT ISSUANCE
51 building construction.and hereby nuthorimrryrescmetives oflbisciry reenter upon the CONSTRUCTIONTAX
U 7 above-nemimed Property for inspection purfmsee. ALTER OR ADD TO MECH.
�7 (We)agree to save,indemnify and keep harmless the City of Cupertino aguimt
liabilities,judgmenes,costs and expenses which may marywayacc eagainsoeid Ciry AIR HANDWNG UNIT(TO ID,OBD CFM)
in conseq once of me eon' of this pe it.
• AIR HANDLING UNIT(OVER 10,000 CFM)
�\
nature,rf Applicros/Canvanor /1` et< EXHAUST HOOD(W/DUCq PAID
HAZARDOUS MATERIALS DISCLOS ^ HEATING UNIT(TO HXLM BTU) Dam Receipt is
Will the applicant or future building occupant store or handle hsaardous maven'I1y TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IW,000 BTU)
CWe,Smmm 25532(.)7 VENTILATION FAN(SINGLE RESID)
13 yes EI No 27
��11II pp I$$SUNCEDA E
Will theapplicanmrfmant umbuildingoceupuseequipmemordeviceewhich emit BOILER-COMP p11P OR 100,01)(I BTU) g- p 1 Q,!
industrious air contaminants ss defined by the Bay Area Air Quality Management BOILER-COMP(OVER WILWO BTU)
District? 11 Yaw ❑No NEW RESIDEN27 00TIAL MECH. SQ.FT. MAY ^ • 1994
I have mad the monstrous Cnsd,materials requirements under Chapter1. Iun understand
of the
if,he lmia Health,does not
cur Cody have.
5,25333 and 25534. 1 undemerd Nn CITY Uh LUYtIi I IIVU
if,he of d does not currently have a tenant.Nat it is my nuance bility m notify the
occupant of the requucmenb which must be met prior to issuance of a Certificate of ,
Occupancy. qZT
Owner ser amhorimd agent Date TOTAL: ISSUED BY: "PI
OFFICE