26734 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEC I RI A 1117RMI'1'NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. /� I'A A
BUILDING DIVISION ,IIIjILUING PROJECT IDENTIFICATION G 34
BUILDsINNGs' 2- ss SANITARY NO. APPLICATION SUBMITTAL DATE
t\
_ 1 r UNIT'# LOT
OWN- SNAME: PHONE: CONTRACTOR'S NAME.: LIC NO:
N/C CON I KOL p
'DITECfAWGINEER: J LIC NO: ADDRESS: Jo
6 S a.4 n V#1 ElJo
CONTACT: PH :._rZs�
ONE
ff.. QTY. ELECTRIC PERMIT PEI? BUILDING PERMIT INFO
BLDG ELECT' P UMH MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DF,CIARATION API'LIANCI?S-RESIDENTIAL 1011 DESCRIPTION
El
mxz lamd,yof6nlh
nml am licevdunderpmvisionsofChapter9(commeneingwith
Vi100 Seainn"lllfl(pof Division 3 ofthe Business and Professions Code,and my license is in PANELS
CWC full force and effec ` �1' A
Fzw Licenx Cl s Lic.# '1�5� 6D UP TO 200 AMPS Vv -
m y Date Gtmramor 201-1000 AMPS
ZOs�i�Z ARCHITECTS D17CLARATION OVER 10g1AMP5 SQ.FT.FLOOR AREA $/SQ.FI'.
CZ-0 I understand my plans shall he used as public records.
m❑F; SIGNS ELECTRICAL
Qyz,-1 Licensed Professional
�y�Q OWNER-BUILOER DECLARATION SPECIAL CIRCUNDMISC.
ex0�� 1 hemhy if ion that 1 um exunpt front he Cmnramm's License Law fiche
Y1�+ . following reason.(Semon 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
0� which requires.permit mnmarmf.lrer,improve,dcmolish,orrtpairanystrai
wwY�: prior to its issuance,also requires the applicant for such pamifto file a signed statement POWER DEVICES
W,<0 that he is licensed pmsuam to the provisions of the Contractor's License Law(Chapter
9(commencing with Section 70001af Division 3 offhe Business and Professions Code) SWIMMING POOL ELECTRIC r ^ �VALI, 0Aj
fy_y
or he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FI%TURLS 77 'y��\"V,'
F Z 4 Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of -
5_G —mono than five hundred dollars($500).
x
€o ❑ I,asownerofthc ro n ,orm NT:W RESIDENTIALELECfR _SQ. J'.
C p pe tu ycmployeeswithwex!forahe(Sce.compensation, n ( STORIES) 'Yl'E CONSTRUCTION
W,3�° and do ProhcwonsCde TheCureisnottim's License
9014,Business
and Professions Cult:The Cm.mctn/s Liana Law fines not apply to an nwna
properly who buildrorimprovestherton,and ws.
M1odoes chwnrkhimsdor
fthroughhisis
cmploytts,providedrhvt such improvementsarenotimcndcdoroffered hrtsele.If, UNITS
however,me huilding o improvcmem Is sold within one yearuf completion,theowner- TOTAL:
builder will hove the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,as ownerolthe property,am exclusively contracting with lmerxd contractors to QTY. : 1, PLUMBING PERMIT PEE' FLOOD ZONE APN
construct the project(Sec.9814,Business a d Profcasions Code:)The Contractor's
License Law does not apply to bnownerofpmpcny whobuilds or improves thereon,and PERMIT ISSUANCE
whoconnacts for such projects with acmnnaRods)licensed pursuant n the Commicmrs ALTER (EA)
License Law. FEE SUMMARY
❑ I am exanpt under Sec. ,B&P C for chis ream
BACK PLOW PRO'1'ECf.UEVICE SANITARY 1 TV DI E N
Owner Dare DRAINS-ILOOHROOFAREACOND. RECEIPT#
, , ,
TI
WORKMAN COMPENSAON DECLARATION SCHOOL TAX Y N
❑ lherthy afRmUhatl haveacenifica¢ofconxm half-insum,orecenificem of FIXTURES-PER TRAP RECEIPT#
Workers'Compensation Insurance ora cenified copy thexof($ec.3800,Lab C.)which PARK RAE Y N
coven all employcks under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RF.CIBPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(FA) PLANCHIiCK FEE
❑ Cerlfied copy ishereby ltmished.
❑ Cmificdcopyi.filedwithtbecityinspationdivision. GRFASFANDUSIRL WASTE INTERCEPTOR GRADING PER
CERTIFICATE OF EXEMPTION FROM WORKERS' GRF,ASETRAP SOILS RE
COMPENSATION INSURANCE
Ghlssenloanoed.ot he ampecd foe permit is Forms hundred doll...0 1110) x SEWER-SANITARY-STORM EA,20017. ENERGY FEE
or less.)
Icenify than he rfennance of Ne work(..which lhispermit is issued,Ishvll WATER HEATER W[VF.NIDELECTR
mol employ any 1P���W'�!''�'ymanner sn y m b bj`ed fr the Workers' PAID
Cnmpcnanicim I Dore-�/#L/7�s WATER SYS'FEMO`REATING Date Recein 0
pp,
ZQ NO]IICE TO APPLICANT:If,after makin Ibis Certificate of Exemption,you should NEW RES]DENTIAL PLMB. S FT,B Q
F (q become subject to Workers Compensation provisions of the Lubar Code.you main
TOTAL:
K. ; forthwith comply auh meh provisions or this permit shall he deemed revnked. BUILDING FEE
a (� CONSTRUCTION LENDING AGENCY SEISMIC PER
z I herehyufion that there is v ennsnunim lendingagency for the performance of ]: ELECTRIC FEE
U O Ne work for which this Permit is issued(Sec.3097.Civ.C.)
Lender's Name
O0 U Lenders Address QFYI. ,'. 5 MECHANICALPFRMIT' FEE PLUMBING FEE
U 1 cenify that I have rtW this application and state the the above informal..is
W c maiect.I agree to comply with ell city and county ordinances aelaws relating to PERMIT ISSUANCE MECHANICAL FEE
r
CL,
7 buildingconwructioo,and henebyamhodx rtpresenwtive.ofrhis city toemeruprt he CONSTRUCTION TAX
U G above-memioned property for inspection purposes. MAER OR ADD TO MECH.
(We)agree to rove 'ode ify and kkkeeee/par
hmless rhe City of Cupertino against
erses
liabilities,judgmeda sts xihoryinanywayaccrueagainstxid City AIR HANDLING UNIT(TO 10,000 CFM)
I.consequence of cg ofthie 11Ir'
AIR HANDLING UNIT(OVER 10,000 CFM)
s
Sigma f pplicam/Commcmr ate EXHAUST❑OOfI(WA)UCI)
PAID
I IAZ RDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam keceiptis
Will the.##Ikea or(more huilding occupant.store or handle hasardovs material III?ATING UNIT(OVER 10(1.000 BTU) TOTAL:
as defined by the Cupenum Municipal Code,Chapter 9.12,and the I leabh and Safety
Cmk,Section 25532(a)Y
El Ye. 11 No VI?NTILATION FAN(SINGLE Rf?SID)
BOILER-COMP OHP OR 100,000 BTU) ISSUANCE DAT'13
Will the applicamerfmum buildingoecupavt useequipmencordeviceswhichemit - QAD
huaurlous in,ommuminams as dented by be Bay Axv Air Quality Management BOILER-COMP(OVER 100.000 ETU)il
District? H. so
❑Yes ❑No NEW RESIDENTIAL MECSQ.FT. �
I have sad the hseardous materials requirements under Chapter 6.95 of the 1997
California Health&Safety Code,Sections 25505,25533 and 25534. I nnder.and Item
if the building does not currently have a tenant,that it is my responsibility to notify the
occupant of the requirements which must be met prior to issuance of o Comficam of
Occupancy.
Owner or emhnrizcd.gem Data TOTAL: ISSUED BY:
OFFICE